Provider Manual

Chapter 25: Physical and Occupational Therapy Program

This chapter contains information about our utilization management program for physical and occupational therapy provided in partnership with Palladian Muscular Skeletal Health.

EmblemHealth has partnered with Palladian Muscular Skeletal Health (Palladian), a specialty network and utilization management organization, to arrange outpatient physical and occupational therapy (PT/OT) services for our members and their eligible dependents in the benefit plans listed below. Through this partnership, Palladian is responsible for the administration of prior approvals, claims payment for professional claims and appeals for denial determinations made on professional claims.

 

In addition, Palladian is responsible for credentialing and re-credentialing of HIP network PT/OT providers. For PT/OT services administered to HIP members at a hospital outpatient facility, Palladian is also responsible for prior approvals after the initial visit. Claims payment and appeals for denial determinations will be handled directly by HIP.

 

The following plans are managed by Palladian:

  • Prime HMO
  • GHI HMO Plans
  • HIPaccess® I and HIPaccess® II
  • Prime POS
  • Prime EPO/ Select EPO
  • Prime PPO/ Select PPO
  • Medicaid Managed Care
  • EmblemHealth Child Health Plus
  • EmblemHealth Medicare HMO
  • Advantage Care Physicians (beginning 4/1/2017)

 

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

  • EmblemHealth EPO/PPO
  • EmblemHealth CompreHealth EPO (Retired August 1, 2018)
  • EmblemHealth Medicare PPO
  • GHI PPO
  • Inspiris
  • Medicare Cost
  • Members whose ID card indicates a primary care physician from one of the following entities:
    • HealthCare Partners (HCP)
    • Montefiore (CMO)
    • Lenox Hill
  • PT/OT services rendered by a podiatrist

 

All members excluded from the PT/OT program are medically managed in the same way as they are for all other services. The referral and prior approval protocols for these excluded members are managed by the utilization review agent listed on the back of the members' ID card.

For GHI HMO Members

The initial referral is valid for the first six visits to the participating PT/OT provider. Within three business days of the initial evaluation, the referred PT/OT practitioner must 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.

 

For HIP Members

For the initial evaluation visit, EmblemHealth's current referral process remains the same. Eligible members require a referral from their primary care physician or an ordering specialist for the initial outpatient PT/OT visit. Please keep a copy of the referral in the patient's files for your records. A copy of the referral may be printed out at the time or after it is created using the Referral inquiry functions on www.emblemhealth.com.

 

After this initial visit, the servicing practitioner or hospital outpatient clinic will need to obtain prior approval directly from Palladian for all subsequent outpatient PT/OT services.

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.

Retrospective Utilization Reviews (RURs) are clinical in nature and may be requested when HIP claims have been denied for a lack of medical necessity or in situations where there is no prior approval on file.

 

Should you receive a claim denial for hospital outpatient physical or occupational therapy from HIP, you must file a RUR with Palladian.

 

Time Frame for RUR Requests

All requests for RURs must be submitted within the time frames specified in your contract with HIP. If your contract does not contain language regarding a specific time frame, then regulatory timeframes (i.e., 45 calendar days from the date of remittance) will apply. A determination will be made and communicated within 30 days of the request.

 

Where to Submit Documentation

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

 

Palladian
Utilization Management Department
2732 Transit Road
West Seneca, NY 14224

 

Palladian will determine medical necessity and either grant the approval or uphold the denial. If you have any questions, you may contact Palladian's customer service department at 1-877-774-7693, Monday through Friday, from 8:30 am to 5 pm.

 

For services that receive RUR approval, HIP will reprocess the claims for the affected dates of service. We ask that you do not resubmit these claims as it may result in a duplicate claim submission and possibly delay payment.

If your GHI HMO claims have been denied for a lack of medical necessity or because there is no prior approval on file and you would like to dispute the denial, you do not request a RUR. You will receive information from Palladian regarding your clinical appeal rights so that you may file an appeal.

 

If your request for RUR of a HIP claim is denied, you will receive information from Palladian regarding your clinical appeal rights. All appeals of RURs will be processed by HIP as indicated in the appropriate Dispute Resolution section of this Provider Manual: Medicaid; Commercial/CHP; or Medicare. All other appeals will follow Palladian's process which follows:

The appeals process for Palladian is the same for GHI HMO and HIP members.

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 written or oral standard or expedited UR appeal or action appeal within 180 calendar days of receiving the original decision. Please note that appeals filed on behalf of Medicaid members must be filed within 90 calendar days of the date of the adverse determination letter. In addition, oral standard appeals must be followed up in writing, expedited appeals do not.

 

To initiate a UR or action appeal, call Palladian's customer service department toll-free at 1-877-774-7693, 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: Utilization Management Department
2732 Transit Road
West Seneca, New York 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 will review the case. When 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. Medicaid members may also be entitled to request a New York State Fair Hearing.

Appeals for denial determinations made by Palladian must be submitted to:

HIP Commercial Plans GHI HMO Plans

Palladian Muscular Skeletal Health
PO Box 368
Lancaster, NY 14086-0368

Palladian Muscular Skeletal Health
Attn: Utilization Management 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
PO Box 2807
New York, NY 10116-2807

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

  • GHI HMO: 1-866-284-2901
  • HIP: 1-877-774-7693 or 1-716-712-2808

 

For instructions on submitting claims, please see the chart below.

Benefit Plan Address Form Required

GHI HMO

GHI
PO Box 2832
New York, NY 10116-2832

CMS-1500

HIP - Professional Providers

Palladian Muscular Skeletal Health
PO Box 366
Lancaster, NY 14086

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

CMS-1500

HIP - Outpatient Facility Providers

HIP Claims Department
PO Box 2803
New York, NY 10116-2803

UB-04

 

PT/OT Benefits

EmblemHealth PPO/EPO and GHI plan members are not covered under the Palladian program. They have a capped, limited benefit of 30 visits per calendar year. PPO members are allowed to go out of network. EPO members may only see network providers.

 

There are no referral or prior approval requirements for these initial base benefit visits. If more visits are needed in a calendar year, the provider may follow the member grievance process in the Dispute Resolution for Commercial/CHP Members chapter.

 

City of New York (Including Unions and Locals)

City of New York members (including all unions and locals) have a base benefit of 16 visits per calendar year for outpatient physical therapy (PT) only, both office-based and hospital-based. They do not have outpatient occupational therapy (OT) as a covered service. OT is only covered as part of home care services.

 

Benefit Extensions

The Benefit Extension process is implemented when additional visits above the base benefit are requested and are provided for under an EmblemHealth EPO/PPO or GHI EPO/PPO member's contract.

Where EmblemHealth EPO/PPO or GHI is listed as the primary insurer, you may submit a benefit extension request from our secure Provider Web site at www.emblemhealth.com. Once signed in, look for the option on the left-hand navigation bar. (The member's primary insurer may also be verified through our secure site.)

You may also request a Benefit Extension Treatment Plan Form for an EmblemHealth EPO/PPO or GHI member by calling:

  • EmblemHealth: 1-877-482-3625
  • GHI: 1-800-223-9870