Introducing: Standardized Prior Authorization Request Form TheMassachusettsHealthCareAdministrativeSimplificationCollaborative*,amultistakeholdergroup committedtoreducinghealthcareadministrativecosts,isproudtointroducetheStandardizedPrior AuthorizationFormandaccompanyingreferenceguide.Thisstandardformmaybeutilizedtosubmita priorauthorizationrequesttoahealthplanforreviewalongwiththenecessaryclinicaldocumentation tosupportthereques.
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How to fill out the Fallon Prior Authorization Form online
Filling out the Fallon Prior Authorization Form online can streamline the process of obtaining necessary approvals for health services. This guide provides a detailed, step-by-step walkthrough to assist users in completing the form accurately.
Follow the steps to fill out the form correctly.
- Click ‘Get Form’ button to access the Fallon Prior Authorization Form and open it for completion.
- Fill in the health plan and fax number at the top of the form. Ensure all details are accurate and correspond with the health plan you are submitting to.
- Complete the required fields under 'Service Type Requiring Authorization' by checking all applicable services. This ensures that you are requesting authorization for the correct procedures.
- Provide the required 'Provider Information,' including the requesting and servicing provider names, NPI numbers, and contact details. Ensure that all fields marked with an asterisk are filled out as they are mandatory.
- Fill in the 'Member Information' section with the patient's details, including their name, date of birth, and health insurance ID number. It is essential to also include the patient's contact information.
- In the 'Diagnosis/Planned Procedure Information,' describe the principal diagnosis and the planned procedure, including ICD-9 codes and CPT/HCPCS codes as required. Make sure to specify the number of units being requested.
- Indicate the service start and end dates accurately to ensure timely processing of the authorization request.
- Review the completed form for accuracy and completeness. Ensure all required documentation and clinical information is attached as necessary.
- Finalize by saving your changes. You can download, print, or share the form as needed for your records or submission.
Complete your prior authorization requests online with confidence!
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Is Fallon NaviCare a Medicare Advantage plan?
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.
Does Fallon Navicare require referrals?
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 Program™.
Does Fallon Wellforce require referral?
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.
Does Fallon Medicare require referrals?
Fallon commercial HMO and Fallon Senior Plan™ 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.
What is Fallon evidence of coverage?
An Evidence of Coverage is a booklet that is part of your contract with us. It describes your complete benefits as well as how to use the plan. You can find information about our grievance, coverage determination and appeal (and exceptions for Part D if the plan includes Part D) processes in your Evidence of Coverage.
Does Fallon Select Care require referrals?
Fallon commercial HMO and Fallon Senior Plan™ 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.
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