New payment arrangements for non-contracted providers

Fallon Health is implementing new payment arrangements for pathology, anesthesiology, emergency, and ambulance services rendered by providers who do not contract with the plan. This applies to our commercial HMO (e.g., Direct Care, Select Care) and Commonwealth Care members. (Does not apply to members of MassHealth, Fallon Senior Plan, Fallon Preferred Care, NaviCare or Summit ElderCare.)

For emergency services, we will pay the usual and customary fee. Fallon is implementing this program to ensure a reasonable reimbursement is paid for services performed by non-contracted providers. We encourage you to enter into a contract for services with Fallon in order to receive jointly-negotiated rates for services rendered—minus any member copayment, coinsurance and deductible.

For ambulance, pathology and anesthesiology services, we will send the member (or subscriber, if the member is under the age of 18) the full amount of the bill, minus any cost-sharing they may have. They will then pay you directly.

Please note: You should continue to bill Fallon first, following the same process that you always have.

If you have any questions regarding this program, please feel free to contact Fallon Provider Relations at 1-866-275-3247, prompt 4, Monday through Friday from 8:30 a.m. to 5:00 p.m.