Criteria, policies and guidelines

Plan policies

Medical policies
Detailed documentation for all current medical policies for treating Fallon members

Payment policies
Payment policies and documentation for a variety of treatments and procedures

Authorization and referrals

Radiology management

  • Fallon partners with eviCore healthcare to provide authorization services for high-tech outpatient elective diagnostic imaging procedures for your patients.
  • Authorization is required for CT scans (including CTA), MRI/MRA studies, Nuclear Cardiac Imaging (NCM), and PET scans.

Referral and prior authorization process
Procedures and processes for referring patients and for requesting a prio authorization

Sleep studies and therapy prior authorization and utilization management program
Fallon partners with Sleep Management Solutions (SMS) to provide sleep diagnostic and therapy management services for selected Fallon product lines.

Care guidelines

Asthma tool kit
The resources in this kit are provided to assist you in caring for your patients with asthma. 

Clinical guidelines
When should teenagers have an eye exam? How often should routine cholesterol screenings be conducted? View our recommended health measures and screenings.

Clinical practice initiatives for NaviCare members
Documentation and guidelines for treating NaviCare members

Guidelines and requirements for NaviCare members in long-term care facilities (pdf)

HEDIS® measures
Measures for preventive health care and condition-specific care.

Pharmacy

ePA (electronic prior authorization tool) Training Guide (pdf)

Pharmacy prior authorization procedures (pdf)