Palladian conducts a Medical Necessity Review Process for all PT/OT services to assess the patient's current medical condition, pain, and progression of treatment. Practitioners and patients will be able to complete and submit the required forms via Palladian's Web site at www.palladianhealth.com. The medical necessity review process is user-friendly and designed to gather concise information from you and your patient to help determine the appropriate course of care.
For GMI HMO Members
The referred PT/OT provider must, within three business days of the initial evaluation, submit the Referral Certification Form through www.palladianhealth.com or via fax to 1-716-712-2817. Palladian will then register the initial six visits.
If additional visits are needed to resolve the condition within the benefit time frame, physical therapy and occupational therapy providers must complete a PT/OT Treatment Form through www.palladianhealth.com or via fax to 1-716-712-2817.
In the case of serious illness or injuries where reasonable medical necessity would indicate treatment continuing beyond the members yearly benefit limit, the therapist may request a benefit extension by contacting GHI HMO directly at 1-877-244-4466.
Failure to submit required forms for additional authorization may result in an administrative denial.
For HIP Members
PT/OT practitioners, whether in private practice or in an outpatient facility, must obtain prior approval from Palladian for the member's second treatment, and each continued treatment thereafter, by submitting the necessary forms through www.palladianhealth.com or via fax to 1-716-809-8324.
- Individual and/or Group Outpatient Practitioners are required to complete the necessary forms prior to the first post-evaluation visit. Forms can be completed online at www.palladianhealth.com or downloaded and faxed to Palladian at 1-716-809-8324.
- Outpatient Facility Services are required, after the initial evaluation, to request prior approval directly from Palladian rather than confirming that a prior approval has been issued and posted to www.emblemhealth.com. For ongoing care, complete and submit Palladian's required forms at www.palladianhealth.com.
Submitting Requests for Medical Review
Medical necessity determinations for future care are based on the completion of three concise clinical intake forms:
These forms are on www.emblemhealth.com and www.palladianhealth.com. The practitioner is responsible for submitting all forms to Palladian for review.
You may submit the completed forms electronically from www.palladianhealth.com or you may fax them to Palladian at 1-716-809-8324.
Following are examples of the forms required for different scenarios:
- For every new patient and when there is a change in the primary diagnosis, the following three forms need to be submitted within five business days of the initial evaluation.
- For any additional follow-up care after the initial authorization, the following two forms need to be submitted within five business days of the "Requested Start Date."
- All requests for additional care may be processed or submitted at www.palladianhealth.com.
Glossary terms found on this page:
Services that have been approved for payment based on a review of EmblemHealth's policies.
A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.
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 hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
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.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
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).
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.
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 medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
A recommendation by a physician that an enrollee receive care from a specialty physician or facility.