News and announcements
July 2024 Connection newsletter
- Changes to prior authorization requirements
- Fallon Health member language and/or alternate format preferences
- Deadline for MassHealth ACO first-time claim and corrected claim submissions
- Helpful clarifications to the provider appeal process
- CAQH: Action needed
- Behavioral health needs in an inpatient setting
- New president and CEO to start at Fallon Health July 1
- And more
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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