Physical and Occupational Therapy Program

03/29/2021

EmblemHealth partners with Palladian Musculoskeletal Health (Palladian), a specialty network and utilization management organization, to manage outpatient physical and occupational therapy (PT/OT) services for Health Insurance Plan of Greater New York (HIP) and EmblemHealth Insurance Company (formerly HIP Insurance Company of New York (HIPIC)), Bridge Program, and SOMOS members. See Excluded Members section.

 

Hospital Outpatient Facility

Palladian administers preauthorization requests for PT/OT services delivered at a hospital outpatient facility. However, claims processing and appeals (Action Appeals for Medicaid and HARP members) for denial determinations of these services are handled directly by EmblemHealth. Prior to submitting a formal appeal of a denied claim, hospital outpatient facilities must submit a retrospective utilization review request directly to Palladian. See the Hospital Outpatient Retrospective Utilization Reviews and Appeals section.

 

Professional Services

Palladian is also responsible for the administration of preauthorization requests for non-hospital settings and claims processing for professional claims. Palladian will administer retrospective utilization reviews, peer-to-peer discussions, and appeals (Action Appeals for Medicaid and HARP members) for denial determinations made on preauthorization requests and on professional claims (excluding members with Medicare plans). 

 

Preauthorizations do not guarantee claims payment. Services must be covered by the member’s health plan and the member must be eligible at the time services are rendered. Claims submitted may be subject to benefit denial. Prior to rendering services, all providers must verify member eligibility and benefits by signing in to emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab..

Palladian is responsible for the credentialing and recredentialing of PT/OT providers who are part of their network. For information on credentialing with Palladian, contact Palladian’s Customer Service at 877-774-7693. All others, see the Credentialing chapter of the Provider Manual and our Join Our Network page. 

The following members, services, and benefit plans are not managed by Palladian:

  • PT/OT services rendered by a podiatrist
  • EmblemHealth Plan, Inc. (formerly GHI) benefit plans
  • Members whose ID card indicates a primary care physician from one of the following entities:
    • HealthCare Partners (HCP)
    • Montefiore (CMO)
  • Members who have not been assigned to a primary care provider (PCP)

These members are medically managed in the same way as they are for other services by the assigned Managing Entity. To determine the Managing Entity, check the member’s ID card or sign in to emblemhealth.com/providers and use the Eligibility drop-down under the Member Management tab. See the Utilization and Care Management chapter of the Provider Manual for applicable rules and preauthorization processes. You may also use the Preauthorization Lookup tool on the provider portal to determine if a preauthorization is required and who is responsible for conducting the review.

 

TIP: Check member ID cards at every visit, regardless of service or reason for the visit.

Palladian conducts a medical necessity review process for PT/OT services to assess the patient’s current medical condition, pain, and progression of treatment. 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. 

Practitioners may complete and submit the required forms listed below to Palladian via their Health Provider Portal at evicore.com/palladian:

NOTE: Failure to submit required forms for preauthorization may result in an administrative denial.

PT/OT providers for Excluded Members, see Who to Contact for Preauthorization.

Professional providers seeing members under the PT/OT Program should submit claims directly to Palladian:

For electronic claims: EDI/Payor ID: 37268

For paper claims:

Palladian Health
P.O. Box 366
Lancaster, NY 14086

 

Contact for claims inquiries: PHInfo@evicore.com

 

PT/OT providers for Excluded Members, see Claims Contacts.

Retrospective utilization reviews (RURs) are clinical in nature and may be requested when claims are denied for a lack of medical necessity or in situations where there is no preauthorization on file. If you receive a claim denial for hospital outpatient physical or occupational therapy from EmblemHealth, you must file an RUR with Palladian.

Time Frame for RUR Requests

All requests for RURs must be submitted within the time frames specified in your provider contracts. If your contract(s) does not contain language regarding a specific time frame, then the appropriate state or federal regulatory time frames apply. A determination is made and communicated within 30 days of Palladian’s receipt of the request.

 

Where to Submit RUR Documentation

All RUR requests, along with medical records and other information related to the case, should be sent to:

 

Palladian
Attn: UM Department
2732 Transit Road
West Seneca, NY 14224

Fax: 716-809-8324

 

Palladian determines medical necessity and either grants the approval or upholds the denial. If you have questions, contact Palladian’s Customer Service department at 877-774-7693, Monday through Friday, from 8:30 a.m. to 5 p.m.

 

For RUR-approved services, EmblemHealth reprocesses the claim(s) for the affected date(s) of service. Do not resubmit claim(s); it may trigger a duplicate claim submission denial and possibly delay payment.

 

Appeals of Hospital Outpatient Facility Retrospective Utilization Reviews (RURs)

While Palladian is responsible for RURs of PT/OT services administered to eligible members at a hospital outpatient facility, appeals for denial determination of RURs are processed by EmblemHealth as indicated in the appropriate Dispute Resolution chapter of the Provider Manual: 

If your request for an RUR of an EmblemHealth claim for hospital outpatient PT/OT is denied, you will receive information from Palladian regarding your clinical appeal rights.

Appeals of Denials for Professional Services – Commercial (including Child Health Plus and Essential Plan) Members
Appeals of denial determinations on professional services for Commercial members follow Palladian’s process. If you do not agree with a decision regarding medical necessity, you may:

  1. Request a peer-to-peer conversation if you have not already discussed the adverse determination with the clinical peer reviewer.
  2. File a standard or expedited utilization review appeal, either written or orally, within 180 calendar days of receiving the original decision. Oral standard appeals must be followed up in writing; expedited appeals do not need to be followed up in writing.

To initiate a utilization review appeal, call Palladian’s Customer Service department toll-free at 877-774-7693, Monday through Friday, from 8:30 a.m. to 5 p.m. You may initiate a written request for an appeal by sending the request to:

 

Palladian Muscular Skeletal Health
Attn: UM Department 
2732 Transit Road
West Seneca, NY 14224

 

You may submit written comments, documents, records, and other information related to the case. A clinical peer reviewer who was not involved in the original decision reviews the case. If Palladian does not change its original decision, you will receive information about your or your patient’s further appeal rights. Once you have completed the first level of the internal appeals process, you are entitled to a New York State External Appeal.

 

Appeals of Denials for Professional Services – Medicaid (including HARP) Members
Appeals of denial determinations on professional services for Medicaid and HARP members follow Palladian's process. If you do not agree with a decision regarding medical necessity, you may:

  1. Request a peer-to-peer conversation if you have not already discussed the adverse determination with the clinical peer reviewer.
  2. File a standard or expedited action appeal, either written or orally, within 60 business days of the date of the adverse determination letter. Oral standard action appeals must be followed up in writing; expedited action appeals do not need to be followed up in writing.

To initiate an action appeal, call Palladian’s Customer Service department toll-free at 877-774-7693, Monday through Friday, from 8:30 a.m. to 5 p.m. You may initiate a written request for an action appeal by sending the request to:

 

Palladian Muscular Skeletal Health
Attn: UM Department
2732 Transit Road
West Seneca, NY 14224

 

You may submit written comments, documents, records, and other information related to the case. A clinical peer reviewer who was not involved in the original decision reviews the case. If Palladian does not change its original decision, you will receive information about your or your patient’s further appeal rights. Once you have completed the first level of the internal action appeals process, you are entitled to a New York State External Appeal. Medicaid members may also be entitled to request a New York State Fair Hearing.

 

Appeals of Denials for Professional Services – Medicare
EmblemHealth directly handles Medicare appeals. The processes for appeals of denial for professional services are described in the Dispute Resolution: Medicare Members chapter of the Provider Manual.