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Pre-authorization means obtaining the Plan’s approval before you receive a medical service or supply. In-Plan participating physicians have been provided with a list of all services that require prior approval and will communicate directly with the 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.
If you choose to receive Out-of-Plan Services, you will be responsible for notifying Atlantis in advance of all non-emergency hospital admissions and elective surgical procedures. Members must complete the Pre-authorization process with Atlantis prior to an elective admission to a Non-Plan hospital, or when admitted to a Plan hospital by a Non-Plan physician. Pre-authorization for inpatient services includes, all elective hospital admissions,both maternity and non-maternity, and also to facilities for hospice, mental health, rehabilitation care, and skilled nursing.
Your subscriber contract provides complete instructions on the Pre-authorization process.
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 and/or FAX your request to AHP at (877-720-3811) at anytime. The AHP voice mail system is also available on weekends and holidays to obtain consultation on urgent/emergency matters. An AHP representative will contact you on the next business day.
Utilization review is a process utilized by HMOs 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, institutional, experimental and/or investigational services. Utilization review will occur whenever judgments pertaining to medical necessity and the provision of services or treatments are rendered. AHP 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 the member 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.
A. 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 3 business days or less after AHP receives the necessary information with which to render a decision. You , your designee, and the provider will be notified by telephone and in writing of the determination.
B. 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 utilization is an example of concurrent utilization review. Decisions regarding concurrent utilization review will be completed within one business day after AHP receives the necessary information with which to render a decision. You, your designee, 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.
C. 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 30 days or less after Atlantis Health Plan receives the necessary information with which to render the decision. The member, member’s designee, and provider will be notified in writing of the determination.
Failure by AHP to make a determination within the required time periods set forth in Article 49 of the Public Health Law shall be deemed to be an adverse determination subject to internal appeal.