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Atlantis Health Plan requires physicians to bill using the HCFA 1500 claim form. The guidelines for completion are the same as required by Medicare when billing, including current CPT codes, place of service codes and appropriate ICD-9 diagnosis codes. Should your staff require further information on the completion of the HCFA form, they may contact Atlantis Health Plan Claims Service.

Physicians interested in submitting claims online should contact Atlantis Health Plan Claims Service.

CO-PAYMENTS

Atlantis Health Plan members are required to pay all necessary co-payments at the time services are rendered. Please refer to the co-payment on the member's identification card. If there is no charge submitted to Atlantis Health Plan for an office visit (X-ray, or test when applicable), then no co-payment is to be collected. Should a member fail to pay the required co-payment, please contact the Atlantis Health Plan Member Services Department so that we might assist your office in the collection process.

EXPLANATION OF PAYMENT

Physicians are requested to bill Atlantis Health Plan for all medical services rendered to members less the co-payment collected, if any. A Remittance Advice (Explanation of Payment) will be forwarded with payment. This report will provide a detailed summary of services rendered and payment information.

MEDICAL RECORD STANDARDS

Access

As stated in the Atlantis Health Plan Participating Physician Agreement, the New York State Department of Health and Atlantis Health Plan have the right to inspect all records including medical records, maintained by participating physicians pertaining to members, and to copy any or all of such records for the purposes of assessing quality of care, coordinating medical care evaluations and audits, determining on a concurrent basis the medical necessity and appropriateness of care provided to members, and in the case of the New York State Department of Health, for such other purposes as the Department shall determine. Participating physicians are required to cooperate in the transfer of members' medical records to other participating physicians, and to assume any associated cost. Participating physicians agree that member's medical records and information shall be treated as confidential so as to comply with all applicable state and federal laws and regulations regarding the confidentiality of medical records and information.

Medical Record Retention

Participating physicians shall retain all member's medical records for a period which shall end not less than six years after the last date on which such member received medical services from physician, or six years after such member shall have achieved the age of majority under New York law, whichever period is longer.

The following Atlantis Health Plan medical record standards have been established to ensure that the providers within our network document good professional medical practice and appropriate health management. Atlantis believes that a complete and thorough record is an essential component to the delivery of quality medical care.

CRITERIA FOR MEDICAL RECORDS CRITERIA:

1. A systematic mechanism for documenting medical information must be present.
2. Within the record, medical information must follow a logical and consistent format.
3. Information should be contained in a manner that will not easily be lost (i.e., forms are secured within a folder, individual records established for each patient).
4. The medical record system should be confidential, with a mechanism in place to assure member confidentiality.

1. Every page in the record contains the patient's name or ID number.
2. Personal/biographical data include address, employer, home and work telephone numbers, and marital status.
3. All entries in the medical record contain author identification.
4. All entries are dated.
5. The record is legible to someone other than the author. A second reviewer examines any record judged to be illegible by one physician reviewer.
6. Significant illness and medical conditions are indicated on the problem list. *
7. Medication allergies and adverse reactions are prominently noted in the record. If the patient has no allergies or history of adverse reactions, this is appropriately noted in the record. *
8. Past medical history is easily identified and includes patient, family, social and environmental aspects/health and serious accidents, operations, and illnesses. For children and adolescents past medical history relates to prenatal care, birth, operations, and childhood illnesses. *
9. For patients 14 years and over, there are appropriate notations concerning use of cigarettes, alcohol, and substance abuse.
10. The documented history and physical examination are appropriate for the presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
12. Working diagnosis is consistent with diagnosis. *
13. Treatment plans are consistent with diagnosis. *
14. Encounter forms or notes have notation, when indicated, regarding follow- up care, calls, or visits. The specific time of return is noted in weeks, months, or PRN.
15. Review for under/over utilization.
16. Consultation, lab, and imaging reports filed in the chart are initialed by the primary care physicians, or some other method is used to signify review. Consultation reports and/or diagnostic tests (normal or abnormal results) have an explicit notation in the record of follow-up plans.
17. The records must be kept in English.
18. There is evidence that preventive screening and services are offered in accordance with the organization's practice guidelines.
19. Unresolved problems from previous office visits are addressed in subsequent visits.
20. If a consultation is requested, the consultant's note must be in the record.
21. An immunization record has been initiated for children, or an appropriate history has been made in the medical record for adults.

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