PCP referral and preauthorization policy and procedure


Primary care referral – A recommendation by which a primary care provider sends a member to another provider for services that are typically outside the PCP’s scope of practice.

Preauthorization – The prospective or concurrent review process used by Fallon Health to determine coverage of a particular medical service. Preauthorization involves the review of eligibility, level of benefits and medical necessity.

Referring provider – The provider initiating the referral

Servicing provider – The provider or facility providing the service

Member self-referral (within product):

  • OB/GYN visits 
    • Annual preventive gynecological visits
    • Medically necessary evaluations and treatment
    • Obstetrical visits
    • Mammogram
    • Oral surgery (impacted teeth only)
    • Routine eye exams
    • Outpatient mental health/substance abuse

    PCP referral procedure

    Referrals for specialty care are required for commercial HMO and Fallon Senior Plan HMO members. POS members have the option of receiving care out-of-network without a referral. PPO members do not need a referral for specialty services.

    1. The PCP refers the member to a specialist within the member’s product for medically necessary care. Contact the specialist by telephone, fax or mail, and provide the PCP’s name, NPI number, the reason for the referral and number of visits approved.
    2. The specialist verifies member’s eligibility through the Fallon online eligibility tool or POS device or by contacting Fallon Customer Service at 1-800-868-5200, Monday through Friday from 8:30 a.m. to 5:00 p.m.
    3. The specialist treats the member according to the PCP’s request and exchanges clinical information with the member’s PCP.
    4. The specialist submits a claim to Fallon with evidence of a referral (i.e., the PCP NPI number) from the member’s PCP. The following information should be entered on the CMS-1500 or electronic equivalent as evidence of the referral:
      1. Box 17 – enter referring provider/PCP’s name
      2. Box 17b – enter referring provider/PCP’s NPI number
      3. Failure to include complete referral information (the referring provider’s name and NPI number) on the claims will result in a denial.
      4. PCP referrals will be accepted retroactively up to 120 days from the date of the Remittance Advice Summary (RAS). Should an initial claim be rejected for lack of a referral number (i.e., the PCP NPI number), the specialist has 120 days from the date of the RAS to resubmit a corrected claim with the provider NPI number. Please note that all corrected claims must be dropped to paper and marked “corrected claim.” Corrected claims cannot be submitted electronically.
      5. If a member does not have a valid referral but visits a specialist for services that require a PCP referral, the specialist should contact the member’s PCP to obtain a PCP referral. If the PCP does not approve the referral, the specialist should inform the member of his or her financial liability and ask the member to sign a waiver of liability.
      6. If a specialist decides that a member needs a service that he/she can not provide, the specialist must consult with the member’s PCP, who will initiate a new referral to the appropriate specialist.
      7. Please note that all services with out-of-product, tertiary, non-contracted and/or Peace of Mind Program™ providers or facilities require a preauthorization.

      Services requiring preauthorization

      The following services require preauthorization for HMO and POS members:

      • All elective inpatient admissions
      • All services with out-of-product, tertiary, non-contracted and/or Peace of Mind Program™ providers or facilities
      • All unlisted CPT-4 and unspecified HCPCS codes
      • Specified DME and prosthetics and orthotics
      • Elective hospital/facility same-day surgery and ambulatory procedures on the procedure codes list
      • Genetic testing
      • Home health services
      • Infertility/assisted reproductive technology
      • Neuropsychological testing
      • Nonemergent ambulance
      • Office-based procedures identified on the procedure codes list
      • Oral surgery services and treatment
      • Oxygen
      • PET scans (for products not participating in MedSolutions)
      • Plastic reconstructive surgery and treatment
      • Transplant evaluation

      Preauthorization procedure

      1. The requesting provider completes the Prior Authorization Request Form and faxes it to 1-508-368-9700.
      2. Fallon will send a determination to the requesting provider, PCP and member.
      3. Please note that Fallon will not process retroactive plan preauthorizations.
      4. PPO members are responsible to notify Fallon of certain procedures, or a penalty may be applied.