Claims Corner — Utilization Review

UTILIZATION REVIEW

Medically necessary services covered by our plans

Palladian to Perform Retrospective Utilization Reviews for Outpatient Physical and Occupational Therapy

As a reminder, HIP, an EmblemHealth company, partners with Palladian Muscular Skeletal Health (Palladian) to administer outpatient physical and occupational therapy (PT/OT) benefits for members in the following HIP plans: HMO, POS, PPO, EPO, Medicare, Medicaid, Family Health Plus, Child Health Plus, Access I and Access II.

As such, please be advised that Palladian manages all requests for retrospective utilization review (RUR) for these outpatient services. RURs are clinical in nature and may be requested when claims are denied for a lack of medical necessity or in situations where no prior approval is on file.

RUR Submissions to Palladian
Should you receive a claim denial from HIP for hospital outpatient PT/OT, you must file an RUR with Palladian. All requests for RURs must be submitted within the time frame specified in your contract with HIP. If your contract does not contain language regarding a specific time frame, then regulatory time frames will apply. 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 retrospective 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 claims submission and a possible delay in payment. If your request for RUR is denied, you will receive information from Palladian regarding your clinical appeal rights. All appeals will be processed by Palladian, with the exception of Medicare appeals, which will be processed by EmblemHealth.

Services and HIP Members Not Managed by Palladian
Excluded from this arrangement are PT/OT services rendered by a podiatrist, as well as members in Medicare Cost, HIP Classic, Vytra, SmartStart and CompreHealth plans. Also excluded are members whose ID card indicates a primary care physician affiliated with one of the following medical groups:

• *Queens-Long Island Medical Group
• *Preferred Health Partners
• *Staten Island Medical Group
• *Manhattan's Physician Group
• Montefiore (CMO)
• Health Care Partners (HCP)
• Lenox Hill

*Palladian will manage the outpatient PT/OT benefits of any member affiliated with one of the four above-mentioned medical groups and covered by one of the following benefit plans: PPO, EPO, Medicare Open Access, Medicare SNP, Access I and Access II.

EmblemHealth Partners with OrthoNet

Beginning February 1, 2010, OrthoNet LLC, on behalf of EmblemHealth, will review medical records for a sampling of submitted professional claims to ensure that the services billed reflect the services documented in the medical record and that such services are properly coded. We have executed a Business Associate Agreement with OrthoNet to ensure HIPAA compliance in all aspects of claims submission and processing.

How Does This Work?
There is no change to your current claims submission process. Claims that fit specific criteria (e.g., amount threshold, CPT code or specialty) will be selected for review. If medical documentation was not submitted with the claim, OrthoNet will send you a letter to request medical records for the claims under review. The letter will indicate the patient's name, their member ID and the date(s) of service. You may fax your documentation to OrthoNet at 1-877-499-9538.

If you receive a request for additional information, please respond as soon as possible to facilitate claims processing.

Please note: OrthoNet will not be conducting utilization reviews or making medical necessity determinations. Should you disagree with the claims payment decision, you are entitled to the appeal rights outlined in the EmblemHealth Provider Manual.

Excluded Members:
OrthoNet will not perform medical claims review for members who:

• Are PPO/EPO members
• Have selected a primary care physician (PCP) affiliated with St. Barnabas Hospital, Montefiore Medical Center (CMO), Health Care Partners (HCP) or Inspiris
• Have selected a PCP with any one of the following physician group practices:
  • Queens Long Island Medical Group
  • Preferred Health Partners
  • Staten Island Physician Practice
  • Manhattan's Physician Group
  • Lenox Hill Medical Group