Eligibility help

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Question:
What are the system requirements to use Provider Tools?

Answer:
The requirements to use the various Provider Tools, including electronic submission are:

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

Download a current version of Internet Explorer.

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Question:
What if I need help using Provider Tools?

Answer:
We'll be happy to assist you. Please contact our EDI coordinators at 1-866-275-3247, option 6, or via email.

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

Answer:
To obtain access for new employees, please complete a Provider Tool and electronic data submission enrollment form (pdf) and fax it to 1-508-368-9996 OR send to:
Fallon Health
Attn: EDI Coordinator
10 Chestnut St.
Worcester, MA 01608-2810

Please notify Fallon immediately at 1-866-275-3247, option 6 to disable access for employees who have terminated employment. 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 site, all information transferred is sent using SSL.

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Question:
I verified that my patient was eligible using the Provider Tools, but my claim was rejected as "Reject not eligible." How accurate is the information that Provider Tools uses?

Answer:
When verifying eligibility, Provider Tools uses up-to-date information at the time of your request. However, enrollment transactions may occur retroactively. Eligibility responses are not a guarantee of payment or authorization of services.

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Question:
I received an eligibility response of "Member Not Found." What does this mean?

Answer:
The response of "Member Not Found" identifies that this member has not been eligible with Fallon for the past 120 days. You may search for dates of services 120 days in the past and 90 days in the future.

It also may indicate that an incorrect ID number, date of birth, or member name was entered. Please check the information and resubmit your inquiry.

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Question:
When searching for a patient's eligibility, "Contact Customer Service" appeared in place of a PCP name. What does this mean?

Answer:
If Fallon does not have a PCP on record for the member you're searching for, "Contact Customer Service" will be displayed as the PCP name and "1-866-ASK-FCHP, press 2" will be displayed as the PCP phone number in your search results. Please inform the member that they should contact Fallon at the phone number indicated to update their member information.

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Question:
Where can I find more information about Fallon's plans?

Answer:
Fallon's eligibility verification will identify the plan in which the member is enrolled. To find out more information please go to the Provider Manual or contact Fallon's Provider Relations Department at 1-866-275-3247, press 4.

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Question:
When verifying my patient's eligibility, I noticed that my phone number is incorrect. How can I update my information?

Answer:
Please call 1-866-275-3247, press 4 or send an email.

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