Atlantis Health Plan

Member Handbook New PCP Request Member Handbook POS Products Healthy New York Benefit Summaries Riders Rx Plans Member FAQ Member Newsletter HIPAA Information Forms Contact Us Atlantis Outpatient Centers

<< Back to table of contents

Appeal Procedures

Adverse determinations will only be made by a clinical peer reviewer of Atlantis Health Plan when requested health services or a level of care are denied because they fail to meet the established written utilization review criteria of Atlantis Health Plan for medical necessity and appropriateness of the level of care.

A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current' and valid non-restricted license, certification or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession and is in the same profession/specialty as the health care provider who typically manages the medical condition.

Notices of adverse determination are made in writing and include:

the reasons for the determination
the clinical rationale, if any
instructions on how to initiate an appeal
notice of availability of the clinical review criteria upon which the determination was based, upon request of you or your designee
specification of any additional information which should be provided to, or obtained by, Atlantis Health Plan in order to render a decision on the appeal.
As a Member, you have the right to designate a representative to file an appeal. Only qualified clinical personnel will review appeals.

You, your designee, or your health care provider may request from Atlantis Health Plan reconsideration or appeal of the adverse determination. Various types of appeals and time frames for responses are provided for, depending on the following circumstances under which the adverse determination was made:

reconsideration within one (1) business day of receipt of the request;
expedited appeal with access to a clinical peer reviewer within one (1) business day and a determination completed in two (2) business days of receipt of necessary information to conduct the appeal;
standard appeal with a determination completed within sixty (60) days of receipt of necessary information to conduct the appeal. Atlantis Health Plan will issue written notification of the appeal determination within two (2) business days.
retrospective review determination is made within thirty (30) days of receipt of necessary information with which to render the decision.

Failure by Atlantis Health Plan to make an appeal determination within the applicable time periods set forth in Article 49 of the Public Health Law shall be deemed to be a reversal of Atlantis Health Plan's initial adverse determination.

<< Back to table of contents