News and announcements

October 2023 Connection newsletter

  • Provider Satisfaction Survey
  • Lesser of contract language for ACO contracts
  • New dental benefit management program
  • Clinical trial workgroup
  • Step Therapy Exception process
  • Community Care expansion

Read past issues of Connection

Community Care Qualifying Payment Amount (QPA) for Non-contracted Providers 

New federal and state requirements concerning surprise billing have taken effect. Fallon Health recently began paying out-of-network claims for the Community Care product pursuant to the federal No Surprises Act. The allowed amount for out-of-network claims covered by the No Surprises Act will be set at the Qualifying Payment Amount (QPA). 

  • Fallon Health is working with our vendor partner ClearHealth to identify claims subject to the No Surprises Act and to determine the appropriate QPA. 
  • For any claims paid in accordance with the No Surprises Act, the Fallon Remittance Advise (RAS) will note at a claim line level “Paid according to the qualifying payment amount (QPA), as defined by the No Surprises Act Regulations.” A Provider Adjustments and Appeals letter with additional details will be included with the RAS. 
  • If an out-of-network provider or facility wishes to initiate a 30-day open negotiation period for purposes of determining the amount of final payment to the provider or facility, they may contact ClearHealth via the secure portal https://provider.clearhs.com or by calling (866) 722- 3773.

Paper claims P.O. Box issues

When shipping paper claims that are not deliverable to a P.O. Box, (via FedEx etc.), please send to the following address:  

Fallon Health Claims- Smart Data Solutions
960 Blue Gentian Road
Eagan, MN 55121

Opioid management program and pain management alternatives

Pharmacy updates

MassHealth.

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