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Utilization Review (UR) 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 judgements pertaining to Medical Necessity and the provision of services or treatments are rendered. The following is a brief description of the process:

Prospective utilization review is the process of determining Medical Necessity prior to the provision of the service. Prior approval and Pre-authorization of services, such as surgery, are examples of prospective utilization review.

Concurrent utilization review is the process of determining ongoing Medical Necessity while the service is being provided. Evaluation of the continued need for an inpatient hospital stay is an example of concurrent utilization review.

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.

Appeals

You have specific rights with regard to the appeal of utilization review decisions that have been rendered by Atlantis Health Plan. There are two broad categories of determinations which give you different rights: a determination where your health care provider was involved in the decision-making process and a determination where your health care provider was not involved in the decision-making process.

Atlantis Health Plan will allow only qualified clinical personnel to make determinations with regard to the provision of your benefits. All notices of denials will include information about the basis of the decision.

The MEMBER HANDBOOK provides a complete description of Utilization Review polices and procedures used by Atlantis, including:

1. The circumstances under which UR will be undertaken;

2. The toll-free telephone number of the Atlantis UR agent.

3. The timeframes under which UR decisions must be made for prospective, retrospective and concurrent decisions;

4. Your right to reconsideration of an adverse determination;

5. Your right to an appeal, including the expedited and standard appeals processes and the time frames for such appeals;

6. Your right to designate a representative; and

7. Your right to an External Appeal of a final adverse determination which was made on the grounds that the health care service was not medically necessary or is experimental or investigational

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