Provider Manual

Chapter 24: Chiropractic Program

This chapter contains information about our network and utilization management program for chiropractic services provided to designated members.

 

 

EmblemHealth has partnered with Palladian Muscular Skeletal Health (Palladian), a specialty network and utilization management organization, to arrange chiropractic services for our members in the benefit plans listed below. Through this partnership, Palladian is responsible for the administration of prior approvals, claims payment, credentialing, recredentialing and appeals for denial determinations, as described in this chapter.

  • GHI HMO
  • GHI HMO - Point of Service
  • GHI HMO - Senior Supplement (Commercial)
  • GHI PPO
  • HIP Access I and HIP Access II
  • HIP Prime (HMO)
  • HIP Prime (POS)
  • EmblemHealth Medicare HMO
  • EmblemHealth Medicare PPO
  • Vytra HMO

 

Members and eligible dependents covered by these plans are allowed unlimited visits to a network chiropractor, based on medical necessity and the meeting of prior approval and referral requirements (according to the member's benefit).

 

All members excluded from the Chiropractic Program are medically managed in the same way as they are for all other services and are subject to consistent utilization review and utilization management standards and protocols.

HIP and Vytra HMO Plans

The initial visit to a chiropractor does not require prior approval. Chiropractors must obtain prior approval from Palladian for the member's second treatment, and each continued treatment thereafter, by completing and submitting the medical necessity review forms online by signing in to www.palladianhealth.com or by faxing them to 1-716-712-2802 for HIP members or to 1-716-712-2803 for Vytra members.

 

GHI HMO Plans

The practitioner providing care or the ordering specialist must provide members with a referral for them to obtain chiropractic services. This initial referral is valid for the first six visits to the participating chiropractor. Within three business days of the initial evaluation, the referred chiropractor must complete and submit the Referral Certification Form online or via fax.

 

To complete and submit the form for the first six visits and any additional visits thereafter, referred chiropractors may complete and submit the Referral Certification Form online after logging into www.palladianhealth.com. They may also fax the completed form (found at the end of this chapter) to 1-716-712-2817. Palladian will then register the visits.

 

GHI PPO Plans

Members may access chiropractic care without a referral or prior approval for no less than the first eight visits, depending on the member's benefit. Chiropractors must obtain prior approval from Palladian for each continued treatment thereafter by submitting the medical necessity review forms online by logging onto www.palladianhealth.com or by faxing them to 1-716-712-2817.

 

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

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 on www.palladianhealth.com. The practitioner is responsible for submitting all forms to Palladian for review. Practitioners may submit the completed forms electronically by logging onto www.palladianhealth.com or they may fax them to Palladian at 1-716-809-8324.

 

Following are examples of the forms required for different scenarios:

 

All requests for additional care may be submitted to www.palladianhealth.com.

For Commercial members, appeals for denial determinations made by Palladian must be submitted to:

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

 

For Medicare members, appeals for denial determinations made by Palladian must be submitted to:

EmblemHealth
Grievance and Appeals Department
P.O. Box 2807
New York, NY 10116-2807

Eligible members may call the following numbers for customer service and more information:

  • HIP: 1-877-774-7693
  • GHI PPO: 1-212-501-4444 (in New York City) or 1-315-432-0826 (in all other areas)
  • Medicare PPO: 1-866-557-7300
  • GHI HMO: 1-866-284-2901
  • Vytra: 1-866-883-0643

Palladian is responsible for the credentialing and recredentialing of participating chiropractors for GHI HMO and HIP. EmblemHealth EPO/PPO and GHI PPO providers contract directly with the plan. Please refer to the chart below:

Benefit Plan Palladian EmblemHealth

GHI HMO

Yes

 

HIP

Yes

 

Vytra

Yes

 

EmblemHealth EPO/PPO

 

Yes

GHI PPO (Commercial)

 

Yes

Medicare Choice PPO

 

Yes

Claims must be submitted in the following manner:

Benefit Plan Address Form Required

HIP and Vytra HMO

Palladian Muscular Skeletal Health
P.O. Box 368
Lancaster, NY 14086-0368

For electronic claims submission, Palladian's Payor ID is 37268.

CMS-1500

GHI HMO

Palladian Muscular Skeletal Health
P.O. Box 307
Lancaster, NY 14086

For electronic claims submission, Palladian's Payor ID is 37268.

CMS-1500

GHI PPO (Commercial)

GHI Claims
P.O. Box 2832
New York, NY 10116

CMS-1500

Medicare Choice PPO

EmblemHealth Medicare PPO
P.O. Box 2830
New York, NY 10116-2830

CMS-1500