Fallon_community_health_plan_inc Prior Authorization Lookup
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Latest Fallon_community_health_plan_inc prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-09-01Fecal microbiota transplantation for recurrent Clostridioides difficile infectionThis policy governs medical necessity and prior authorization requirements for fecal microbiota-based therapies (including conventional FMT and FDA-approved products Rebyota and VOWST) to prevent recurrent C. difficile infection for Fallon Health members and selected Fallon products.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Skilled Nursing Facility (SNF) level of careDefines Fallon Health clinical coverage criteria for SNF level of care, who requires prior authorization, and when admission and continued stay in a SNF are covered for Fallon products and members.All fallon_community_health_plan_inc updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-03-01Adult Foster Care (AFC) payment and coverage policyGoverns eligibility, prior authorization, billing, and reimbursement for Adult Foster Care services for NaviCare HMO SNP members living in qualified AFC settings; outlines service definitions, visit requirements, leave/alternative caregiver rules, and telehealth allowances per MassHealth guidance.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Community-Based LTSS Services Clinical Coverage CriteriaDefines Fallon Community Health Plan's clinical coverage criteria, prior authorization requirements, provider qualifications, service limits, and documentation standards for a range of community-based long-term services and supports (LTSS) for NaviCare HMO SNP members.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Day Habilitation (DH) — Coverage Criteria and Prior AuthorizationDefines Fallon Health coverage, prior authorization, clinical criteria, documentation, coding, exclusions, and limitations for community-based Day Habilitation services for members with intellectual or developmental disabilities.All fallon_community_health_plan_inc updates
- Prior AuthEff. 2025-11-25Surgery for Obstructive Sleep Apnea — Clinical Coverage CriteriaClinical coverage criteria governing prior authorization and medical necessity determinations for surgical treatments of obstructive sleep apnea for Fallon Health plan members, including Medicare Advantage and Community Care products; includes references to InterQual criteria and exclusions.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-01Hypoglossal Nerve Stimulation Clinical Coverage CriteriaDefines Fallon Health prior-authorization and medical necessity criteria for hypoglossal nerve stimulation (HNS) implants and related procedures for Fallon Health plan members, including product- and population-specific variations and exclusions.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Orthognathic Surgery Clinical Coverage CriteriaClinical coverage criteria for orthognathic surgery (surgical correction of mandibular and/or maxillary skeletal abnormalities) including applicability to Fallon Health products and Medicare/Community Care variations; affects providers seeking prior authorization for members.All fallon_community_health_plan_inc updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-07-01Dental Services Fallon Medicare Plus and NaviCare Payment PolicyDefines Fallon Community Health Plan's reimbursement and prior authorization rules for dental services provided to Fallon Medicare Plus and NaviCare HMO SNP members, including when Medicare may pay and how supplemental dental benefits are administered.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Durable Medical Equipment Clinical Coverage CriteriaDefines Fallon Community Health Plan's medical necessity, prior authorization, rental/purchase, and exclusion rules for durable medical equipment for plan members, and describes hierarchy of guidance applied by product (Medicare, MassHealth, Dual, Community Care, PACE).All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Home Health Services Clinical Coverage CriteriaDefines medical necessity, authorization, and documentation requirements for home health services provided to Fallon Health members and describes program variations for Medicare Advantage, MassHealth, NaviCare, and PACE. Affects providers requesting prior authorization for home health services.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-05-01Lung Transplantation — Clinical Coverage CriteriaClinical coverage criteria for single or bilateral lung transplantation (including pediatric considerations, lobar and re-transplantation) applicable to Fallon Health products; governs prior authorization and medical necessity determinations for covered members.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Kymriah (tisagenlecleucel) clinical coverage criteriaDefines Fallon Community Health Plan's medical necessity, prior authorization, and coverage criteria for Kymriah (tisagenlecleucel) for applicable Fallon products and describes clinical context and exclusions for pediatric and adult hematologic indications.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Luxturna (voretigene neparvovec-rzyl) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for Luxturna for Fallon Community Health Plan members, including product description, medical necessity criteria, coding, and payer-specific variations (Medicare, MassHealth). Applies to Fallon Health products listed in the policy.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-01Zolgensma (onasemnogene abeparvovec-xioi) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for single-dose intravenous Zolgensma for pediatric patients under 2 years with SMA, applicable to Fallon Health products including Fallon Medicare Plus, NaviCare, and Community Care.All fallon_community_health_plan_inc updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-03-01Dental Services - MassHealth ACO Payment PolicyDefines Fallon Community Health Plan's reimbursement, coverage, billing, prior authorization, and documentation expectations for dental services affecting MassHealth ACO members and providers furnishing dental, oral/maxillofacial surgery, and maxillofacial prosthetics services.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2025-03-01Transplants, Solid Organ Clinical Coverage CriteriaDefines Fallon Community Health Plan's coverage policy, prior authorization requirements, and clinical criteria for solid organ transplants (liver, kidney, pancreas, intestine, heart, heart‑lung and related combinations) for applicable Fallon products; affects providers requesting transplant authorization and transplant centers.All fallon_community_health_plan_inc updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-01-01Drugs and Biologicals Payment Policy — Physician/Clinician‑Administered DrugsGoverns reimbursement, billing, prior authorization, and reporting requirements for medically necessary non–self-administered drugs and biologicals under Fallon Community Health Plan products; affects contracted providers, hospitals, clinics, PACE programs, and others administering medical-benefit drugs.All fallon_community_health_plan_inc updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-01-01Retroactive Authorization Requests Payment PolicyGoverns 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.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-01Capsule endoscopy (esophagus, small bowel, colon) — Coverage and prior authorizationDefines Fallon Health coverage, prior authorization, and medical necessity criteria for capsule endoscopy of the esophagus (CPT 91111), small bowel/esophagus through ileum (CPT 91110), and colon (CPT 91113) for specified Fallon products.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-09-01Cochlear Implants Clinical Coverage CriteriaDefines Fallon Health coverage, prior authorization, and medical necessity determination processes for cochlear implantation and related components across Fallon products; applies to clinicians requesting services for Fallon members.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-09-01Proton Beam Therapy (PBT) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for proton beam therapy applied to Fallon Health products, including Medicare Advantage, MassHealth, NaviCare, PACE, and Community Care members.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-09-01Vagus Nerve Stimulation (implantable and noninvasive) Coverage CriteriaDefines Fallon Health coverage, prior authorization, and medical necessity criteria for implantable vagus nerve stimulation (VNS) and addresses noninvasive/transcutaneous VNS; applies to Fallon Community products listed and notes Medicare/MassHealth variations.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-08-01Deep Brain Stimulation (DBS) Clinical Coverage CriteriaClinical coverage criteria for deep brain stimulation (DBS) including indications, limitations, device approvals, required provider/facility capabilities, and pediatric considerations; applies to specified Fallon Health product lines and MassHealth/Community Care members. Prior authorization is required.All fallon_community_health_plan_inc updates
- Prior AuthClinical/Medical PolicyEff. 2024-08-01Hyperbaric Oxygen Therapy (HBOT) Clinical Coverage CriteriaClinical coverage criteria and prior authorization requirements for hyperbaric oxygen therapy across Fallon Health products, including Medicare Advantage, MassHealth ACO, and select plan lines; describes covered indications, exclusions, coding guidance, and use of InterQual criteria for medical necessity determinations.All fallon_community_health_plan_inc updates
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Tool Description
Search Fallon_community_health_plan_incprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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