Criteria, policies and guidelines

Plan policies

Medical policies
Detailed documentation for all current medical policies for treating Fallon Health members

Payment policies
Payment policies and documentation for a variety of treatments and procedures

Authorization and referrals

InterQual medical necessity criteria
Log in to view the criteria that Fallon Health uses to guide coverage determination decisions

Radiology management

• Fallon Health partners with eviCore healthcare to provide authorization services for high-tech outpatient elective diagnostic imaging procedures for your patients.
• Authorization is required for MRI/MRA studies, Nuclear Cardiac Imaging (NCM), and PET scans.
  Please note: As of June 1, 2026, CTs and MRIs of the brain no longer require prior authorization.

Sleep studies and therapy prior authorization and utilization management program
Fallon Health partners with CareCentrix to provide sleep diagnostic and therapy management services for selected Fallon Health product lines.

Behavioral health medical necessity criteria
Fallon Health partners with Carelon Behavioral Health to provide behavioral health services.

Durable medical equipment and home health services
Fallon Health partners with IHCS for authorization services for certain types of medical equipment and home health services

Care guidelines

Asthma tool kit
The resources in this kit are provided to assist you in caring for your patients with asthma. 

Clinical guidelines
When should teenagers have an eye exam? How often should routine cholesterol screenings be conducted? View our recommended health measures and screenings.

Clinical practice initiatives for NaviCare members
Documentation and guidelines for treating NaviCare members

Guidelines and requirements for NaviCare members in long-term care facilities (pdf)