Information about tiering

Fallon Health is committed to giving all of our members access to a network of high-quality, cost-efficient plan physicians and hospitals

How does tiering work?

Physicians - Direct Care and Select Care

All tiering is based on quality and cost-efficiency measures, with the exception of the following physician specialties which are based on cost-efficiency measures only: allergy/immunology, gastroenterology, hematology/oncology, orthopedics, podiatry and urology.The tiering works as follows:

***Tier 1 (excellent): This tier includes plan physicians practicing at an excellent level of quality and cost-efficiency. You will pay the lowest copayment when you see a Tier 1 plan physician.

**Tier 2 (good): This tier includes plan physicians practicing at a good level of quality and cost-efficiency, or a plan physician with insufficient cost-efficiency or quality data. You will pay the prevalent (mid-level) copayment when you see a Tier 2 plan physician.

*Tier 3 (standard): This tier includes plan physicians practicing at a standard level of quality and cost-efficiency. You will pay a higher copayment when you see a Tier 3 plan physician.

Not Tiered/Insufficient Data (NT/ID): This designation includes providers that did not have sufficient data for tiering and providers that belong to a specialty or subspecialty that is not being tiered by Fallon Health. These specialists are subject to a Tier-2 copayment.

Hospitals - Select Care only

The tiering works as follows:

***Tier 1 (excellent): Hospitals practicing at the most cost-efficient level. You will pay the lowest copayment when you use a Tier 1 hospital.

**Tier 2 (good): Hospitals practicing at a good to above-average level of cost-efficiency. You will pay the prevalent (mid-level) copayment when you use a Tier 2 hospital.

*Tier 3 (standard): Hospitals practicing at a standard level of cost-efficiency. You will pay a higher copayment when you use a Tier 3 hospital.

Not Tiered/Insufficient Data (NT/ID): Includes hospitals that did not have sufficient data for tiering. These hospitals are subject to a Tier 2-level copayment.

 

 

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