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Please refer to the Restrictions, Exclusions, and Limitations section of your Atlantis Health Plan Subscriber Contract for a complete description of restrictions, exclusions and limitations to your benefits.

Pre-authorization

Pre-authorization means obtaining Atlantis Health Plan's approval before you receive a medical service or supply. Participating physicians have been provided with a list of all services that require prior approval and will communicate directly with Atlantis Health Plan in order to receive such approval. In general, Pre-authorization is required for all elective inpatient admissions, all outpatient surgical procedures, certain diagnostic and treatment procedures and some medical equipment. Upon receipt of a request for Pre-authorization by your physician, Atlantis will review the clinical findings for medical necessity. If the proposed admission, procedure, service or supply is a Covered Service and we agree that it is Medically Necessary, approval will be given to the physician. This prospective utilization review assures that the treatment you receive is appropriate for you and is delivered in the most cost-effective setting.

Utilization Review

Atlantis Health Plan's Utilization Department is open Monday through Friday from 9 a.m. to 5 p.m. and can be reached toll free at 1-800-270-9072. If you are unable to contact us during these times, you may leave a voice-mail message at the above phone number. The Atlantis Health Plan voice-mail system is also available on weekends and holidays to obtain consultation on urgent/emergency matters. An Atlantis Health Plan representative will contact you on the next business day.

Utilization review is a process utilized by Health Plans to monitor how physicians, hospitals and ancillary providers are providing services. Utilization Review is defined as the process of determining the necessity of medical services, either with regard to professional or institutional services. Utilization review will occur whenever judgments pertaining to medical necessity and the provision of services or treatments are rendered. Atlantis Health Plan will not, during retrospective review, revise or modify the specific standards, criteria, or procedures used for the utilization review of procedures, treatment, and services delivered to you during the same course of treatment. There are three types of utilization review, which may be used at Atlantis Health Plan: Prospective, Concurrent and Retrospective. The following is a brief description of each and the time frames involved in each.

1. Prospective
   Prospective utilization review is the process of determining medical necessity prior to the provision of the service. Prior approval and authorization of services, such as elective surgery, are examples of prospective utilization review. Decisions regarding prospective utilization review will be completed in three (3) business days or less after Atlantis Health Plan receives the necessary information with which to render a decision. Both you and the provider will be notified by telephone and in writing of the determination.
2. Concurrent
   Concurrent utilization review is the process of determining ongoing medical necessity while the service is being provided. Evaluation of the continued need for inpatient hospitalization is an example of concurrent utilization review. Decisions regarding concurrent utilization review will be completed within one (1) business day after Atlantis Health Plan receives the necessary information with which to render a decision. Both you and the provider will be notified in writing and by telephone, of the amount of extended services approved, a summary of all services approved to date, the dates and duration of services approved, and the date of the next concurrent review date.
3. Retrospective
   Retrospective utilization review is the process of determining medical necessity after the service has been provided. Evaluation of Emergency Room utilization to determine if the conditions were met to conform to the definition of an emergency service is an example of retrospective utilization review. Decisions regarding retrospective utilization review will be completed within thirty (30) days or less after Atlantis Health Plan receives the necessary information with which to render the decision. You and the provider will be notified in writing of the determination.

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