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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.
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.
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.
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:
- The Chiropractic Treatment Form - completed by the participating therapist
- The Chiropractic Intake Form - completed by the patient
- The Chiropractic Outcomes Form - completed by the patient; or the Pediatric Outcomes Form - completed by the parent or guardian of patients under the age of 18
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:
- 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.
- The Chiropractic Treatment Form- completed by the therapist
- The Chiropractic Intake Form - completed by the patient
- The Chiropractic Outcomes Form - - completed by the patient
- 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."
- The Chiropractic Treatment Form-- completed by the therapist
- The Chiropractic Outcomes Form- completed by the patient
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 For electronic claims submission, Palladian's Payor ID is 37268. |
CMS-1500 |
GHI HMO |
Palladian Muscular Skeletal Health For electronic claims submission, Palladian's Payor ID is 37268. |
CMS-1500 |
GHI PPO (Commercial) |
GHI Claims |
CMS-1500 |
Medicare Choice PPO |
EmblemHealth Medicare PPO |
CMS-1500 |
See the following pages for our Chiropractic Program forms:
