Connection supplemental articles and policies - September 2014

Supplemental articles

Payment policies

(Fallon Health and Fallon Total Care) 
Revised policies – effective November 1, 2014
The following polices have been updated; details about the changes are indicated on the policies.

  • Claims Auditing Software Payment Policy – Updated the discussion about reductions for multiple procedures.
  • Evaluation and Management Payment Policy – Updated the discussion about evaluation and management services billed with preventive visit codes.
  • Home Health Care Payment Policy – Updated the billing and coding discussion related to HIPPS codes. 
  • Lab and Pathology Payment Policy – Updated discussion about drug testing code reimbursement.
  • Preventive Services Payment Policy – Updated discussion about preventive services.

What’s new

Fallon’s new transparency tool adds an incentive twist

In order to comply with the Affordable Care Act (ACA) and Chapter 224 state legislation that requires all health insurers to provide real-time cost transparency for their members by October 1, 2014, Fallon Health—in partnership with Compass Healthcare Advisers—has established the Fallon SmartShopper program.

The program provides real-time cost transparency for all Fallon commercial plan members and incentive rewards for many of our commercial group members. The program ranks health care providers based solely on cost and geography, then offers an incentive reward to participating members who:

  • Shop for their health care procedure/service using the Fallon SmartShopper program and;
  • Get their procedure/service done at one of the cost-effective options provided by the program.

Fallon SmartShopper will match the claims from where the member utilized services. If the member shopped for the cost-effective option at least 24 hours prior to the service, they will be eligible for an incentive reward. The amount of the incentive is based on the type of service received.

Fallon SmartShopper determines cost-effectiveness of health care options based on where the member lives, and the analysis is done on a service-by-service basis. For example, the same facility that is cost effective for an MRI might not be as cost effective for a CT scan. A facility could also be cost effective within one specified geography, but not in another.

It all depends on a facility’s actual costs as they relate to other facilities/options within a reasonable, accessible distance to the member. That also includes the member’s own home as there are certain services/procedures that are more cost effective when administered at home (e.g., Remicade).

This online tool utilizes Fallon’s contracted rates, and provides members with current Fallon pricing ranges to show cost. We do not share actual pricing as it may vary based on the specific procedure code used in the billing process.

If you have any questions about Fallon SmartShopper, please call the Provider Relations department at 1-866-275-3247, prompt 4.

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Doing business with us

Fallon Health selected as finalist in strategic use of QNXT

For our success in implementing and using QNXT™, Fallon Health was selected as a finalist among other health plans at TriZetto’s annual payer conference.

TriZetto is our health care IT partner that offers this core administration system we began using in 2010. We successfully upgraded to a newer QNXT version in 2012 and continue to leverage the QNXT application to support our business functions and drive efficiency. 

In the category of “Excellence in Operations," Fallon was cited for the comprehensive approach we’ve taken with configuring QNXT to support our diverse product portfolio and, in particular, our success with responding to the demands of health care reform. 

We continue to experience high auto-adjudication rates for claim processing across our diverse health care products and also have streamlined our sponsor-carrier program configuration, thereby creating efficiencies and consolidating billing. 

What's next?
We're now preparing to upgrade to QNXT's next version, which offers enhancements in claim processing, customer service and provider management in addition to integration opportunities with other systems. 

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Let’s connect

Testing Wisely – Avoiding antibiotics for viral respiratory illnesses

Choosing Wisely logoTo continue our “Testing Wisely” series, this month we are putting the spotlight on antibiotic utilization recommendations from the Choosing Wisely® campaign. 

As you may recall, Choosing Wisely is an initiative of the ABIM Foundation that aims (1) to raise awareness about the overuse of certain tests and (2) to help physicians and patients engage in conversation and together make effective care choices that are based on each patient’s individual situation.

The Choosing Wisely campaign also has caught our attention at Fallon Health, where our interest is in improving quality in a cost-effective way.

As part of the Choosing Wisely campaign, the American Academy of Pediatrics makes the following recommendation regarding antibiotic utilization:

“Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis). Although overall antibiotic prescription rates for children have fallen, they still remain alarmingly high. Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contribute to higher health care costs and the risks of adverse events.”

A review of the HEDIS® rates in our network showed that our providers rank in the 90th percentile for appropriate treatment of children with URI and pharyngitis—and of adults with bronchitis. At Fallon, we attribute this adherence to our high quality provider network, and we want to take this opportunity to commend you, the providers in our network, for these excellent results!

To learn more about the Choosing Wisely campaign in Massachusetts visit

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A provision of the Affordable Care Act (ACA) may have removed one more barrier for the smoker who is contemplating another quit attempt.

Now, in line with the ACA, Fallon Health commercial plans cover all Food and Drug Administration-approved tobacco cessation medications (nicotine and non-nicotine.) Fallon Total Caresm and Fallon MassHealth already covered all cessation medications for two quit attempts per year.

With easier access to nicotine-replacement therapy and other cessation medications—and no out-of-pocket costs (if the prescription is filled at a network pharmacy)—we expect to see more quit attempts and hope that even more patients will be asking their providers about quitting.

Requiring a prescription for an over-the-counter (OTC) medication will facilitate, we hope, more conversations about quitting. Free cessation medications and more provider–patient conversations about quitting sound like a win–win scenario.

And, the final element that could help your patient who smokes really win is Fallon Health’s Quit to Win (QTW) program!

Some of QTW’s current coaching staffers have been assisting quitters for more than15 years. Over that time, they note that the “typical quitter” has changed somewhat. Tobacco products have surely changed in form and potency, and then there’s the ever-popular and unregulated electronic cigarette.

Accordingly, we continue to adapt Quit to Win and enhance the member experience. QTW has launched weekly conference calls in which members can hear from a qualified Quit Coach and interact with some other quitters.

This modality provides peer support and professional advice without the need for travel. Members simply dial in, enter a passcode, and receive the advice and support they need—toll-free, hassle-free, while in the comfort of their own homes.

QTW continues to provide free individual telephonic coaching for all Fallon plan members. Quit to Win is also on Twitter (@QuitToWin) and the QTW text message support program (free to all Fallon plan members) is more popular than ever.

Stay tuned for more details. Please let us know how QTW can enhance your provider experience and better serve our members in your care. Call 1-508-368-9540 or 1-888-807-2908, or e-mail us at

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MassHealth: Updates of behavioral screening Appendices

MassHealth includes developmental and behavioral health (mental health and substance use disorder) screens in the list of Early Periodic Screening, Diagnosis and Treatment (EPSDT) Services and Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) services in accordance with Massachusetts regulations.  

Effective July 1, 2014:

  1. MassHealth has revised Appendix W (EPSDT/PPHSD periodicity schedule). Three tools have been added to the list of MassHealth-approved standardized behavioral health screening tools for children under the age of 21. 
  2. MassHealth has revised Appendix Z (EPSDT/PPHSD screening services codes) to reflect the accurate description of CPT Service Code 96110.

For these updated appendices, please go to the CBHI site.

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