Who is Palladian Muscular Skeletal Health?
Headquartered near Buffalo, NY, Palladian is a health care service provider focusing on medical specialties that address muscular skeletal injuries in conjunction with rehabilitation, ongoing wellness and care coordination.
What is Palladian’s association with HIP?
Effective October 1, 2009, Palladian will be the administrator for outpatient physical and occupational therapy services (PT/OT) for HIP Health Plan of New York members with HMO, POS, PPO, EPO, Medicare, Medicaid, Family Health Plus, Child Health Plus, Access I and Access II plans.
Are there any excluded members?
Yes. The following members are excluded from this arrangement:
• Members receiving PT/OT services rendered by a podiatrist.
• Members in Medicare Cost, HIP Classic, and EmblemHealth CompreHealth plans
• Members whose ID card indicates a primary care physician from the following entities: Queens-Long Island Medical Group, Preferred Health Partners, Staten Island Physicians Practice, Manhattan Physicians Group (MPG), Montefiore (CMO), and Health Care Partners (HCP).
• Members in Vytra health plans.
• Smart Start health plans.
There are no policy and procedure changes for these excluded members. HIP’s current referral and prior approval protocols continue to apply. Contact the managing entity on the back of the member’s ID card for the applicable utilization review agent and claims submission address.
What impact will this have on my practice?
Palladian will be the administrator for outpatient PT/OT in an office or outpatient setting only. This includes credentialing, claims processing and reimbursement, verification of member eligibility, medical necessity review, and all provider service issues relating to PT/OT.
Facility Outpatient Services: Palladian will be the administrator of the medical necessity review process only – all other services will be administered through HIP.
What impact will this have on my fee schedule?
Fees will not be negatively impacted. In fact, Palladian will implement a quality-based pay-for-performance system based on key clinical metrics to recognize quality care and administrative efficiencies for its network practitioners who deliver it. More information on this program will follow in future correspondence from Palladian. Palladian is currently reviewing all fee schedules and will have these made available prior to October 1, 2009.
What are the referral requirements for an initial visit?
Overall, HIP’s current referral process remains the same for the initial evaluation visit. HIP members will require a referral from their primary care physician or an ordering specialist for the initial outpatient PT/OT visit. HIP’s current referral requirements remain the same for the initial evaluation visit. HIP members will require a referral from their primary care physician or an ordering specialist for the initial outpatient PT/OT visit. However, the process of entering a referral has changed slightly. After entering HIP’s website, choose ‘PRIOR APPROVAL’ and select either Office Services, or Outpatient Services, to receive a referral. It is recommended that you keep a copy of the referral in the patient’s files for your records. In addition, Palladian is requiring that a copy of the prescription from the ordering provider is kept on file.
Facility Outpatient Services: After the initial evaluation visit, hospital outpatient clinics will need to request prior approval directly from Palladian, rather than confirming that a prior approval has been issued and posted to the HIP Connected Web site at hipusa.com.
NOTE: If a referral has been issued by HIP, prior to 10/01/09; the referral will be honored after 10/01/09. Palladian’s medical necessity review process begins once the HIP referral visits have been exhausted.
Why is Palladian implementing a Medical Necessity Review Process?
Palladian will be implementing a Medical Necessity Review Process for all PT/OT services to assess the patient’s current medical condition, presence of red flags indicating potentially serious underlying medical conditions, severity of symptoms, overall health (including physical and mental function), as well as the provider’s evaluation of contraindications to PT/OT care, symptoms, function, co-morbidities, and prognosis. This process is designed to gather concise information from you and your patient in order to help direct your patient through the appropriate course of care. Prior approval from Palladian is required for all PT/OT services beyond the initial evaluation visit.
Who is required to complete and submit the medical necessity review forms?
All providers providing outpatient PT/OT services to HIP members with an HMO, POS, PPO/EPO, Medicare, Medicaid, Family Health Plus, Child Health plus, Access I and Access II benefit plan that are not assigned to a primary care physician from the Queens-Long Island Medical Group, Preferred Health Partners, Staten Island Medical Group, Manhattan Physicians Network, Montefiore (CMO), or Health Care Partners (HCP) are required to complete this process.
• Individual and/or Group Outpatient Services: Providers are required to complete the necessary forms within five (5) business days of the ‘Requested Visit Start’ date entered on the PT/OT treatment form. Forms can be completed online or downloaded at www.palladianhealth.com/providers and faxed to Palladian at 1-716-809-8324.
• Facility Outpatient Services: For outpatient facility services after the initial evaluation, prior approval must be requested by the facility from Palladian directly rather than confirming that a prior approval has been issued and posted to the HIP Connected Web site at hipusa.com. For ongoing care, complete and submit Palladian’s required forms at www.palladianhealth.com/providers.
What is the process I need to follow for medical review?
The medical review process applies to individual, group and facility outpatient services. Medical necessity determinations for care beyond the initial evaluation are based on the clinical needs of the patient as documented on the appropriate treatment forms. In order for a determination to be made, all forms must be completed in their entirety. Keep in mind, if information is missing, you will be asked to provide the missing information, which may delay the decision-making process.
It is the provider’s responsibility to submit the appropriate forms listed below to Palladian for review. The patient’s stage of care will determine the appropriate form(s) and are addressed below in questions 10-12. Both the provider and patient may complete and submit forms online at www.palladianhealth.com or the provider only may fax the required forms to Palladian at 1-716-809-8324.
• The PT/OT Treatment Form is to be completed by the provider.
• The PT/OT Intake Form is to be completed by the patient.
• The Outcomes Form is to be completed by the patient.
• The PT/OT Advanced Treatment Form is to be completed by the provider.
Facility Outpatient Services: For facility outpatient services, prior approval must be obtained from Palladian directly rather than confirming that a prior approval has been issued and posted to the HIP Connected Web site at hipusa.com.
What forms must be completed for the initial visit?
For every new patient the following three (3) forms need to be submitted within five (5) business days of the ‘Requested Visit Start Date’ entered on the PT/OT Treatment Form:
• PT/OT Treatment Form – completed by the provider
• PT/OT Intake Form – completed by the patient
• Outcomes Form – completed by the patient
What forms must be completed if additional care is required?
For additional follow up care, for the same primary region of complaint, the following forms need to be submitted within five (5) business days of the ‘Requested Visit Start’.
• Outcomes Form – completed by the patient
• PT/OT Treatment Form – completed by the provider
• Advanced Treatment Form:
i. Online submissions: If additional information is necessary for a determination to be made, this form will automatically be made available for the Provider to complete.
ii. Paper submissions: This form must be completed by the participating Provider and submitted along with the other forms when it is the 3rd request or greater. Failure to do so will result in an incomplete submission and delay the outcome.
What forms must completed if there is a change in the primary diagnosis?
When there is a change in the primary region of complaint of an existing patient the following three (3) forms need to be submitted within five (5) business days of the ‘Requested Visit Start date’
• PT/OT Treatment Form – completed by the provider
• PT/OT Intake Form – completed by the patient
• Outcomes Form – completed by the patient
How do I submit the medical necessity treatment forms?
Use either method below to submit treatment forms:
• Palladian’s Web site – To maximize efficiency and reduce the amount of paperwork in your office, we strongly encourage you and your patients, to complete and submit the appropriate form(s) online. The online process is user-friendly, and walks you and your patient through each form, question by question, saving you and your staff time and unnecessary paperwork, and providing you with an immediate response to the care plan in order to help your patient return to optimal health.
In order to utilize the online submission process, you and your patients must register at Palladian’s Web site at the appropriate links below.
Patient Link: http://www.palladianhealth.com/members/
Provider Link: http://www.palladianhealth.com/providers/
Once the registration process is complete, you will have access to instructions on how to submit the appropriate forms and to retrieve patient information. You will also be able to verify patient eligibility and view your claims history.
• Fax – Providers may fax the required forms directly to Palladian at 1-716-809-8324. It is the responsibility of the provider to ensure all forms are completed in their entirely and properly submitted. Missing or insufficient information will constitute an incomplete submission and will be returned to the provider. Patients may not submit forms directly to Palladian and may not be held liable for charges with the exception of co-payments, co-insurance and deductibles for visits rendered if the visits were denied due to timely submission. ALL forms (member and provider) must be faxed together, in order to constitute a complete submission. Paper submissions are supported only until December 31, 2009.
FAX NUMBER: 1-716-809-8324.
What if I disagree with the decision made after medical necessity review?
If you do not agree with a decision regarding medical necessity, you may:
1. Request a peer-to-peer discussion, unless you have already talked about the adverse determination with Palladian’s Clinical Reviewer.
2. File a written or oral standard or expedited Appeal/Action Appeal, within 180 calendar days of receiving the original decision. Please note: Action Appeals filed on behalf of Medicaid and Family Health Plus members must be filed within 90 business days of the date of the adverse determination letter.
To initiate an Appeal/Action Appeal, contact Palladian’s Customer Service Department toll-free at
1-877-774-7693, Monday through Friday, 8:30 am to 5:00 pm. You may initiate a written request for an appeal by sending the request to:
Palladian
Utilization Management Department
2732 Transit Road
West Seneca, NY 14224
You may submit written comments, documents, records and other information related to the case. A Clinical Reviewer who was not involved in the original decision will review the case. In cases where Palladian does not change its original decision, Palladian will give you information about your/your patient’s further appeal rights. Once you have completed the first level of the internal appeals process, you may be entitled to a New York State External Appeal. Medicaid and Family Health Plus members may also be entitled to request a New York State Fair Hearing.
Where are claims for reimbursement submitted?
• Individual and/or Group Outpatient Providers: Participating and non-participating providers can submit claims as indicated below:
• For dates of service prior to October 1, 2009, submit to HIP
• For dates of service on or after October 1, 2009, submit electronically through your billing clearinghouse (Palladian’s Payor ID is 37268) or via hard copy to:
Palladian
P.O. Box 270
Lancaster, NY 14086
• Facility Outpatient Services: Claims should continue to be submitted to HIP. Note: Facility outpatient
services billed on UB04 should be submitted to HIP, consistent with current process.
Is there a Web site available for more information?
Yes! We recommend and encourage you to become familiar with Palladian’s Web site. This user-friendly site was designed with the provider in mind, allowing you to spend more time with your patients. You can verify member eligibility, view claims history, and complete and submit all treatment forms, thus providing you with an immediate response. You can also access policies and procedures, provider manuals, clinical guidelines, newsletters, and important updates that will keep your practice informed and current. Visit Palladian’s Web site at www.palladianhealth.com for more information.
Who can I contact if I have more questions?
Palladian’s Customer Service department will be happy to assist you with any further questions.
Customer Service is available Monday through Friday from 8:30 am – 5:00 pm ET at 1-877-774-7693 or
1-716-712-2808.
Will ‘Durable Medical Equipment’ (DME) be reimbursed?
DME items will not be reimbursed by Palladian, if such items are dispensed by your office, please refer to HIP.
What if the patient does not speak English?
Palladian is pleased to announce that the medical necessity review forms completed by the patients (PT/OT Intake and Outcomes) will soon be available online in Chinese, Russian and Spanish.
