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.
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 at emblemhealth.com/providers.