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I. Medical Necessity and Appropriateness
Services and benefits provided under this Certificate of Coverage must be Medically Necessary and appropriate, as determined by the Plan.
Medically Necessary means:
“A service, treatment, procedure, equipment, drug, device, or supply provided by a hospital, physician, or other provider of health care that is required to identify or treat a Member’s bodily injury or sickness and which is determined by Atlantis Health Plan to be:
1. Consistent with the symptom(s) or diagnosis and treatment of the Member’s bodily injury or sickness;
2. Appropriate under the standards of acceptable medical practice to treat that bodily injury or sickness;
3. Not solely for the convenience of the Member, physician, hospital, or other provider of health care;
4. The most appropriate service, treatment, procedure, equipment, drug, device, or supply which can be safely provided to the Member, and
5. The most economical manner of accomplishing the desired result.”
J. Non-Covered Services
The Member is completely responsible for payment of non-covered services.
K. Payment for Services
Payments for covered services provided by a provider under contract to Atlantis Health Plan will be made directly to the provider.
L. Reports, Records and Confidentiality
The Plan is entitled to receive information reasonably necessary to administer the Group Contract from any provider of services to the Subscriber and covered dependents. By accepting coverage under this Certificate of Coverage, the Subscriber authorizes each provider to disclose facts pertaining to the care, treatment, and health of the Member, submit reports to the Plan, and permit Atlantis to copy the Member's records.
All medical records are confidential documents. Access to these files is strictly limited. All Atlantis personnel, consultants, contractors or delegated agents are required to sign a statement of understanding of the Plan’s policies and procedures regarding confidentiality of proprietary information at the time of hiring, or signing of agreement or contract, or renewal of contract.
Non-English Speaking Enrollees
If you do not speak English or prefer to communicate in a language other than English, our Member Services staff can assist you in understanding your coverage and/or with any other questions/concerns, you may have. Multi-lingual staff members or translation services are available.