Employer FAQ

To better serve our Fallon Health employers, we have compiled some of the most frequently asked questions below.

Don't see your question listed here? Let us know and we'll work on adding it to our list!

On this page:

Provider network

Benefits and eligibility

Employer Tools


Question:
What is the difference between Direct Care, Steward Community Care and Select Care?

Answer:
Direct Care and Select Care are our two HMO networks.

Direct Care (a limited provider network) is a subset of the Select Care network, custom-built around some of the state’s premier physician groups and hospitals, giving you access to quality providers at a significantly lower premium cost.

Steward Community Care (also a limited provider network) was built in partnership with Steward Health Systems. It is available to members throughout Eastern Massachusetts and it includes all of the Steward Health Care System community doctors and hospitals.

The Select Care network offers a broader choice of providers to help us better meet the needs of employers who have personnel throughout western, central and eastern Massachusetts. Learn more about our networks.

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Question:

How do members select a physician?

Answer:
HMO members are required to select a primary care provider (PCP) from internal medicine, family practice or pediatrics. The PCP has the primary responsibility for coordinating the overall health care for the member, and is required to maintain 24-hour-a-day, 7-day-a-week coverage for Fallon members.

Members can search through a database of physicians online or contact the Customer Service Department. Customer service representatives, as well as representatives in the Access Department, are available to assist the member in selecting a PCP.

Even if a member has a PCP at the time of enrollment, he or she still must notify Fallon of his or her PCP. If a member does not select a PCP upon enrollment, a representative will follow up with the member through phone calls and letters requesting that the selection process be completed. A member who fails to select a PCP may be assigned to one in the appropriate geographic area.

Members may switch their PCP at any time, either online or by calling the Customer Service Department at 1-800-868-5200 (TRS 711).

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Question:

Where can members learn more about physicians than just their name and specialty?

Answer:
The Massachusetts Board of Registration in Medicine Physician Profile System offers a wealth of information on physicians registered to practice medicine in the Commonwealth. This includes education history, disciplinary actions, and honors and awards.

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Question:
Does Fallon offer discounts on fitness center memberships?

Answer:
We do offer reduced membership rates at certain fitness facilities. Fallon members receive a fitness reimbursement that can be combined with fitness facility discounts or used for more than just gym memberships. The It Fits! fitness reimbursement can be used for town sports programs, ski lift tickets and season passes, yoga classes, aerobics classes, sports camps, road race fees and more.

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Question:

Does Fallon cover out-of-state employees?

Answer:
Fallon Health has developed a number of options that allow you to provide coverage to your out-of-state employees.

Fallon Preferred Care (PPO)
Fallon Preferred Care is a preferred provider organization which has a network of more than 800,000 providers and over 4,000 health care facilities nationwide through Private Healthcare Systems and MultiPlan.

General out-of-area care
All Fallon members enjoy the security of coverage for out-of-area emergencies and urgently needed care (defined as care needed right away for a minor emergency, such as a cut that requires stitches, a broken limb or abdominal pain). Members are covered for the initial treatment of any emergency. An emergency medical condition is a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) serious jeopardy to the health of the individual (or unborn child); 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part. The member should go to the nearest emergency room for care. Fallon Health requests that the member, or someone acting on his or her behalf, contact the member's primary care physician as soon as medically possible after receiving care.

In the case of urgently needed care that is not life-threatening, the member is instructed to seek care at the nearest medical facility if he or she is outside of their plan service area and to call Fallon as soon as medically possible.

We also cover specific services for students living outside of the service area, as long as they are authorized in advance. The services are subject to standard copayments and include:

  • Nonroutine medical office visits
  • Diagnostic lab and X-ray connected to a nonroutine office visit
  • Nonelective inpatient services if we are notified within at least 48 hours of the admission
  • Outpatient service to treat the abuse of or addiction to alcohol or drugs for up to 20 office visits per calendar year
  • Outpatient services to diagnose and/or treat mental conditions
  • Short-term rehabilitation services (including physical, occupational and speech therapy). Coverage for physical and occupational therapy is provided for up to 20 visits per calendar year per illness or injury (combined with any in-area visits). Coverage for speech therapy is determined by medical necessity.

The out-of-area student benefit excludes coverage for:

  • Routine physicals
  • Gynecological exams
  • Vision screening and hearing screening
  • Maternity care
  • Routine preventive care
  • Outpatient surgical procedures that could be delayed until return to our service area
  • Durable medical equipment
  • Second opinion
  • Home health care
  • Nonemergency prescription medicine
  • Chiropractic services.

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Question:

What are Fallon's participation guidelines?

Answer:
Fallon Health prefers that 75% of eligible full-time employees be enrolled in all health plans offered by the employer, excluding those who waive due to spousal coverage. Groups that have lower participation level will be quoted at the underwriter's discretion. Fallon requires the employee to work at least 30 hours per week for full-time or 20 hours part-time and receive an employer contribution to health care. Fallon can be offered alongside other carriers.

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Question:

What are the system requirements to use Employer Tools?

Answer:
The requirements to use the various Employer Tools are:

  • an Internet connection
  • a web browser
  • a username and password supplied by Fallon Health

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Question:

What if I need help using Fallon Health's Employer Tools?

Answer:
We'll be happy to assist you. Please contact our EDI coordinators at 1-800-333-2535, ext. 69968, or via email.

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Question:

How can I give Employer Tools access to new employees and remove access for employees who no longer work for me?

Answer:
To obtain access for new employees, please complete an Employer Tools Registration Form and send to:

Fallon Health
Attn: EDI Coordinator
10 Chestnut St.
Worcester, MA 01608-2810

You can also fax the form directly to the EDI Coordinators at 1-508-368-9996.

Download the Employer Tools Registration Form.

When someone leaves your organization, please contact us at 1-800-333-2535, ext. 69968, to disable their access to Employer Tools. Also, if you feel the security of a password has been compromised, please notify Fallon immediately.

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Question:

How can I be sure the information is secure going over the Internet?

Answer:
This site uses 128-bit Secure Sockets Layer (SSL) encryption, the highest level of encryption currently available. Once you are logged into the Fallon Web site, all information transferred is sent using SSL. When you're accessing pages on www.fallonhealth.org, there is a lock icon located on the bottom right of your browser window, which verifies that the site is secure. (Here is what it looks like - SSL Secured (128 Bit))

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Question:

Can another Fallon employer view my information?

Answer:
No. Fallon limits access to employer information by your employer identification number. Fallon is committed to keeping your information—and that of your employees—secure and confidential.

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Question:

I need to end coverage for an employee who was terminated one month ago. Why am I being told the termination effective date that I have entered is not correct?

Answer:
You can't enter a date outside of your retro period. The termination effective date is calculated by counting back the number of days in your retro period from the current date.

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Direct Care is a plan with a limited provider network. This plan provides access to a network that is smaller than Select Care. In this plan, members have access to network benefits only from the providers in Direct Care. Please visit our Find a Doctor tool or consult the Direct Care provider directory to determine which providers are included in Direct Care. A paper copy can be requested by calling our Customer Service Department at 1-800-868-5200.