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  • Request For Claim Review Form - Fallon Community Health Plan

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Request for Claim Review Form Clear Form COMPLETE ALL INFORMATION REQUIRED ON THE REQUEST FOR CLAIM REVIEW FORM . INCOMPLETE SUBMISSIONS WILL BE RETURNED UNPROCESSED. Please direct any questions regarding.

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Fallon commercial HMO and Fallon Senior Planâ„¢ HMO members require referrals from their PCP to receive care from a specialist. POS (FlexCare Select) members have the option of receiving out-of-network care without a referral. PPO members do not need a referral for specialty services.

Because Wellforce is made up of many provider practices, you will have to get a referral from your PCP to see a Wellforce Care Plan specialist. You will also need to get a prior authorization from your PCP to see an out-of-network specialist.

The referring provider completes the required sections of the request for prior authorization form and faxes the form to Fallon Prior Authorization at 1-508-368-9700.

Fallon Community Health Plan offers NaviCare HMO SNP, a Medicare Advantage Special Needs Plan, and NaviCare SCO, a Senior Care Options program. NaviCare is a Coordinated Care plan with a Medicare contract and a contract with the Massachusetts Medicaid program.

Direct Care PCP referral is required for in-network specialty care. Out-of-network specialty care requires prior authorization. Members are eligible for Fallon's Peace of Mind Programâ„¢.

You may file an appeal within 60 calendar days of the date of the notice of the coverage decision.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232