Criteria, policies, and guidelines

Medical policies

Documentation and guidelines for treating Fallon Health Weinberg-PACE members
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Payment policies

Up-to-date policies on payment for medical services. Each policy includes an overview, policy and criteria, an explanation of when services are covered, and any exclusions.
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Authorization and referrals

Each PACE plan member is assigned to an Interdisciplinary Team. PACE provides participants with all the care and services covered by Medicare and Medicaid, as approved by the interdisciplinary team, as well as additional medically necessary care and services not covered by Medicare and Medicaid. With the exception of emergency care and out-of-area urgently needed care, all care and services provided to PACE plan members must be approved by the interdisciplinary team.

Care guidelines

Fallon Health Weinberg's Care and Utilization Management uses national, evidence-based criteria that are reviewed annually by a committee of health plan and community-based physicians. This group determines the medical appropriateness of selected services requested by physicians and other providers. These criteria are approved as being consistent with generally accepted standards of medical practice, including prudent layperson standards for emergency room care.

We also develop in-house medical and behavioral health criteria, making use of local specialist input and current medical literature, as well as guidelines from the Centers of Medicare & Medicaid Services (CMS) and the State of New York.

Criteria are available upon request.