Electronic data submission

Electronic data submission of health care transactions provides quicker adjudication and processing of data. Due to the regulations imposed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, all formatting for electronic health care transactions must be in the ANSI X12 formats by October 16, 2003.

Fallon Health offers two methods of submission of health care transactions:

Direct submission to Fallon

You may submit claims directly to Fallon with no transaction fees. Direct submission requires that you submit health care transactions in the national standard formats. Fallon offers the following transmission methods:

  1. VPN
  2. Secure file transfer over the web (10 MB maximum file size).

If you are interested in submitting electronic health care transactions, please contact us at 1-866-275-3247, option 6, or email us to request to become a trading partner.

Our EDI coordinators will work with you to set up a username, password and mailbox. Next, we will perform testing to ensure that file transmissions meet HIPAA requirements. When testing is complete, you will be notified that Fallon is ready to receive production files.

Companion Guides for EDI implementation

All the guides linked below are PDFs.

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Clearinghouse submission

You may send claims to Fallon electronically by using a clearinghouse. To send your claims via this method, your office will need to enroll with Fallon's contracted clearinghouse. Once enrolled, all you need to do is send your claims data through to the clearinghouse. The clearinghouse will then pass the file through standard data specifications and send it directly into our claims payment system.

Please note: You must be sure to notify the clearinghouse of your decision to submit claims to Fallon through their system before attempting to do so. You are required to provide NPI number to the clearinghouse.

Fallon’s primary clearinghouse contracts are with:

Additionally, claims submitted to these clearinghouses will be automatically redirected to Fallon:

If you are interested in working directly with us, you can also register for Fallon Health’s provider tools, including eligibility verification. You can also use our paper claims form.

System downtimes 

Routine downtime is scheduled weekly from 7 a.m. to 11 a.m. on Sundays and 6 p.m. to 11 p.m. on Thursdays to support maintenance and enhancements for all EDI transactions. Non-routine downtime will be communicated via email at least one week in advance. Emergency unscheduled downtime will be communicated to trading partners via email within one hour following the determination that emergency downtime is needed.


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