Fallon Health Prior Authorization

Coverage: Fallon Health Massachusetts products; not Fallon Weinberg in New York. Confirm product and network responsibility.

Start with the reviewed Fallon Health resources below. Confirm the member's current plan, the payer's operating status, and the requested service before scheduling care or submitting a request.

At a glance

• Use ProAuth to check and request applicable medical authorizations. Community Care referrals require the PCP referral NPI where applicable. Radiology uses eviCore and pharmacy uses OptumRx under the relevant instructions. Login is required.
• Community Care referrals require the PCP referral NPI where applicable. Radiology uses eviCore and pharmacy uses OptumRx under the relevant instructions. Login is required.

Where to verify prior authorization requirements

• Verification resource 1

How to submit prior authorization requests

• ProAuth medical authorization workflow.

• No direct topic-specific link was captured in the current research set.

Information commonly required

• Not clearly published in the researched sources.

Turnaround notes and caveats

• Community Care referrals require the PCP referral NPI where applicable. Radiology uses eviCore and pharmacy uses OptumRx under the relevant instructions. Login is required.

Provider resources

• Official policy source (official)
• Official policy source (official)

Sources

Update notes

Last updated: 2026-10-30.

• Reviewed official indexed FAQ and ProAuth guidance. Retained the adjustment rule without inventing an initial filing deadline.
• Direct page retrieval returned HTTP 403; public indexed official text was available. Confirm the current complete instructions through provider access before operational use.