Universal Request for Claim Review Form for providers 

In an effort to streamline the claims review process for providers, a new form is available. This form was created by the Massachusetts Health Care Administrative Simplification Collaborative, which includes Fallon Health. 

All participating health plans will now be using the Request for Claim Review Form. The reference guide, attached to the form, provides guidance on submission and filing. This new form is among a multi-step initiative to help streamline processes for providers.

This form replaces Fallon's Provider Claims Adjustment Request Form and the Provider Appeals Request Form.

To file the Request for Claim Review Form, mail or fax to:

Fallon Health
Attn: Request for Claim Review/Provider Appeals
PO Box 211308
Eagan, MN  55121-2908

Fax: 1-508-368-9890

For more information about the collaborative, visit www.hcasma.org. If you have any questions, call us at 1-866-275-3247, prompt 4.