Retroactive Authorization Requests Payment Policy
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Governs Fallon Health's handling of retroactive prior authorization requests for services requiring authorization across Fallon Health products; affects providers submitting authorization requests for services and admissions.
Fallon Health will no longer allow authorization requests after the service is rendered for all Fallon Health products, except Summit ElderCare.
Providers may still submit appeals for extenuating circumstances such as enrollment/eligibility mismatch or technology malfunctions.
Authorization and Retroactive Request Rules
Authorization requirements and retroactive requests
Covered with the following requirements and limitations:
ALL of the following
Authorization requirement
- Authorization is required for all elective admissions.
- Authorization is required for specified services including, but not limited to, infertility services, genetic testing, high‑tech radiology, certain surgical procedures, and certain DME items.
- Authorization is required for any service rendered by a provider who is non‑participating with the Plan.
- Providers must submit authorization requests in advance to ensure an authorization decision is received prior to the service date.
- If a prior authorization is not obtained in advance of the service, the claim will be denied.
- Effective January 1, 2025, Fallon Health will no longer allow authorization requests after the service is rendered for all Fallon Health products, except Summit ElderCare; retroactive authorization requests are eliminated to align with industry practice.
- Providers may refer to the Procedure Code Lookup Tool to determine which codes require prior authorization.
Exceptions and appeals
- A provider appeal will only be granted for extenuating circumstances, such as enrollment/eligibility mismatch or technology malfunctions.
- For continuation of services (e.g., DME or infusion), providers should submit additional clinical information prior to future service dates for authorization of continued services.
Codes and Historical Submission Window
What Providers Must Do
Prior authorization required; retroactive requests eliminated effective Jan 1, 2025
Authorization is required for all elective admissions and for specified services (for example, infertility services, genetic testing, high‑tech radiology, certain surgical procedures, certain DME, and any service by a non‑participating provider). Providers must submit authorization requests in advance; Fallon Health will no longer accept authorization requests after the service date effective January 1, 2025 for all Fallon Health products except Summit ElderCare. Claims submitted without prior authorization will be denied; providers may file an appeal only for extenuating circumstances (such as enrollment/eligibility mismatch or technology malfunctions).
- Determine prior‑authorization requirements using Fallon’s Procedure Code Lookup Tool before the service date.
- Submit authorization requests in advance to ensure a decision is received prior to the service date.
- For ongoing services (e.g., DME continuation or infusion), submit clinical information before future service dates to authorize continued services.
- If prior authorization is not obtained in advance, expect claim denial; appeals are limited to extenuating circumstances.
Terminology
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