Retrospective Utilization Reviews (RURs) are clinical in nature and may be requested when HIP claims have been denied for a lack of medical necessity or in situations where there is no prior approval on file.
Should you receive a claim denial for hospital outpatient physical or occupational therapy from HIP, you must file a RUR with Palladian.
Time Frame for RUR Requests
All requests for RURs must be submitted within the time frames specified in your contract with HIP. If your contract does not contain language regarding a specific time frame, then regulatory timeframes (i.e., 45 calendar days from the date of remittance) will apply. A determination will be made and communicated within 30 days of the request.
Where to Submit Documentation
All RUR requests, along with medical records and other information related to the case, should be sent to the following address:
Utilization Management Department
2732 Transit Road
West Seneca, NY 14224
Palladian will determine medical necessity and either grant the approval or uphold the denial. If you have any questions, you may contact Palladian's customer service department at 1-877-774-7693, Monday through Friday, from 8:30 am to 5 pm.
For services that receive RUR approval, HIP will reprocess the claims for the affected dates of service. We ask that you do not resubmit these claims as it may result in a duplicate claim submission and possibly delay payment.
Glossary terms found on this page:
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.