Fallon Health fields Accountable Care Partnership Plans in central and western Massachusetts — three as of the April 2023 state roster (Fallon 365 Care with Reliant, Fallon-Atrius, and the Berkshire Fallon Health Collaborative), a lineup worth re-verifying given ownership shifts since. For ABA, Fallon publishes no distinct policy of its own: behavioral health runs through Carelon, on the state-baseline criteria and the Massachusetts Standard ABA PA Form. Fallon's plans were among the six in MassHealth's 2026 supervision audit and received first-wave recoupment letters.
Fallon has no published ABA criteria of its own — its MassHealth plans defer to Carelon's UM on the state-baseline rules: PA required for assessment and treatment on the Massachusetts Standard ABA PA Form, authorizations in 6-month periods, no published hour caps, medical necessity per EPSDT. Plan-level submission specifics (including whether Fallon requests route through Carelon's ProviderConnect like MBHP's) aren't published — confirm the channel with Carelon before the first submission rather than assuming the MBHP flow.[1][2]
First, the roster: the 2023 ACPP lineup may have shifted — Atrius's ownership changes in particular make the Fallon-Atrius entry worth confirming before onboarding a family who names it. Second, the audit: Fallon is named among the six ABA-administering plans in MassHealth's CY2024 supervision-ratio audit and received recoupment letters in the first wave, so the 1:10 97155-to-97153 floor applies to Fallon claims with the same force as everywhere in the Carelon universe.[2]
The questions that decide whether a family can start with Fallon Health (MassHealth ACPPs), and what they have to bring. Each maps onto something intake should ask on the first call.
EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure.[5]
The standard form names them, and the list is broader than "send them to a developmental pediatrician." For autism it requires "A comprehensive assessment completed by a licensed physician (i.e. PCP, etc.), advanced practice registered nurse, physician's assistant, or psychologist experienced in the diagnosis and treatment of ASD with developmental or child/adolescent experience which aligns with DSM criteria across ASD core deficits." For the 1/1/2026 pathway it requires instead "A diagnosis of Down Syndrome (Trisomy 21) confirmed by genetic testing." Note the two signatures are different people: the diagnostician writes the assessment, while the form itself "should" be completed by the BCBA rendering and/or supervising the services — an analyst the performance specification requires to be a LABA licensed under 262 CMR 10.00. Fallon takes the Massachusetts Standard ABA PA Form through Carelon, so these are the operative requirements; no Fallon-specific diagnostic criteria are published.[6]
No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate.[6]
No referral and no physician order is a condition of authorization. The Massachusetts Standard ABA PA Form has no referral field and is completed by the rendering or supervising BCBA/LABA, and the performance specification's referral language is about timeliness rather than permission: "Fourteen calendar days from referral is the Medicaid standard of timely provision for services established in accordance with 42 CFR 441.56(e)," with a waitlist duty (and an obligation to hand caregivers other regional providers' contact information) where the provider cannot start inside it. What the state does require is PCP evidence in the chart rather than at the door: the complete medical record must hold "Referral and assessment documentation" and "Documentation confirming physical examinations by a PCP," and the continued-services pages ask for a dated primary-care care-coordination entry.[3][6]
Ask the plan: Carelon Behavioral Health provider relations for the Fallon line of business — confirm the MBHP performance specification is applied verbatim.
Carelon decides for Fallon, on the federal clock. Carelon's current Massachusetts addendum (Fallon Health section) lists MassHealth non-urgent decisions "Within 7 Calendar Days" and urgent decisions "Within 72 hours from request." Both apply to pre-service and concurrent review. Under the EOHHS contract "based on 42 CFR Part 438," the member, representative or provider may request an extension of up to 14 calendar days. "When the specified time frames for standard and expedited prior authorization requests expire before Carelon makes a decision, an adverse action notice will go out to the member on the date the time frame expires." No ABA reauthorization lead time is published for Fallon. The standard form allows continued-services requests in up to 6-month windows.[7][8][6]
Ask the plan: Carelon (Fallon Health program): the lead time it wants before an ABA authorization ends.
Fallon pays last for MassHealth ACO members, and its authorization rules still apply when it is secondary. Fallon's April 2026 billing manual says "For services to be considered for payment as a secondary insurer, Fallon Health's policy and procedures for referrals and authorizations must be followed." So get the Fallon/Carelon ABA PA even when commercial coverage is primary. Bill the primary first and send its EOB with the claim. Dependent children follow the birthday rule: "the insurance of the parent whose birth date occurs first in the calendar year." Behavioral-health claims go to Carelon. Its Fallon BH manual (Sept 2021 revision) requires secondary claims "with a copy of the primary insurance's explanation of benefits report and received ... within 60 days of the date on the EOB." Fallon's general billing manual allows 120 days from the other carrier's EOB, so hold to the shorter 60-day window for ABA. Use the TPL Indicator Form to report other coverage to EOHHS. MassHealth's rule adds that a primary denial for missing PA or for being out of network forfeits the secondary payment (130 CMR 450.316(B)). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid."[9][10][11][12]
Ask the plan: Carelon (Fallon program): confirm the current BH secondary-claim filing window. The only Fallon BH manual posted is the September 2021 revision.
Not published. Neither the Massachusetts Standard ABA PA Form nor the Carelon/MBHP performance specification sets a maximum age for the diagnostic evaluation — the form asks for the current ICD-10 diagnosis and, on a "Request for initial evaluation," a copy of the comprehensive assessment, but names no recency window. What the form does date is utilization, not diagnosis: the continued-services page makes the BCBA attest whether at least 75% of the previously authorized direct-service hours were used.[6][3]
Ask the plan: Carelon Behavioral Health provider relations for the Fallon line of business — confirm the MBHP performance specification is applied verbatim.
Permitted at the family's request, with no code list and no POS rule. The ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." No per-code restriction, modifier or place-of-service code is published. The specification published at providers.masspartnership.com is MBHP's; Carelon has published no separate Fallon ABA specification that could be located.[3]
Ask the plan: Carelon Behavioral Health provider relations for the Fallon line of business — confirm the MBHP performance specification is applied verbatim.
Coverage decides whether Fallon Health (MassHealth ACPPs) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Fallon’s MassHealth ACPPs route ABA to Carelon, and the MassHealth-wide supervision band is the floor the state audited against: no less than 10% of Behavior Technician direct service hours in LABA supervision, not above 25% without documented clinical rationale, minimum one hour per month for members at 10 or fewer direct hours per month. The specification published at providers.masspartnership.com is MBHP’s; Carelon has not published a separate Fallon-specific ABA specification that could be located.[3]
Ask the plan: Carelon Behavioral Health provider relations for the Fallon line of business — confirm whether the MBHP performance specification is applied verbatim.
Massachusetts is a no-cap state that nonetheless has one published per-day number. There are no annual, lifetime or unit-of-service ceilings on the EPSDT benefit, and 101 CMR 358.03 is a rate regulation, not a limit regulation — it fixes per-15-minute rates and states they are “full compensation” including “necessary administration and professional supervision associated with patient care.” The only per-day cap in the performance specification is for group instruction, which “may occur up to 4.5 hours a day as clinically indicated, in groups of 2-8 Members.” No per-code MUE regime is published, so what bites in practice is medical-necessity review and the supervision-ratio audit, not a unit edit.[4]
Ask the plan: Carelon provider relations for Fallon; the rate regulation is statewide, the claim edits are not.
Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. No Fallon-specific deviation was located.[3]
Ask the plan: Carelon provider relations for the Fallon line of business.
Yes — its MassHealth ACPPs carry the state-baseline EPSDT benefit, with behavioral health (including ABA authorization) administered by Carelon on the Massachusetts Standard ABA PA Form in 6-month periods.
No distinct Fallon ABA criteria are published — it defers to Carelon UM and the state baseline. Confirm submission mechanics with Carelon directly.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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