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When discharge needs are anticipated or when institutional placement is required, discharge planning should be initiated as soon as possible after admission to the hospital. Discharge planning includes both preparation of the patient for the next level of care and arrangement for placement in the appropriate care setting. The attending Physician and/or the Hospital Discharge Planner should contact Atlantis Health Plan's Case Manager/Utilization Review Nurse in the Utilization Management Department.

When the attending physician initiates discharge planning, Atlantis Health Plan's Utilization Management staff will assist with the process in any possible way. Discharge planning referrals should be to participating providers and/or facilities unless an out-of-plan request is pre-authorized by the plan's Medical Director.

RETROSPECTIVE REVIEW

Retrospective utilization review is the process of determining medical necessity after the service has been provided, based on the current professionally accepted standards of care and criteria used in the pre-authorization and concurrent review processes for the same conditions and diagnoses.

Decisions regarding retrospective review will be completed within thirty (30) days after Atlantis Health Plan receives the necessary information with which to render a decision. The member and provider will be notified in writing of any determination. In the event of an adverse determination, the letter will state the clinical basis for the denial and include instructions for filing an appeal.

Failure by Atlantis Health Plan 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.

RECONSIDERATION

If an adverse determination is made without discussing the plan of care with the requesting provider who recommended the treatment under review, then that provider may request a reconsideration of the adverse determination.

Reconsideration will be done within one (1) business day of receipt of the request, and will be conducted between the member's health care provider and the clinical peer reviewer who made the initial determination (or a designated substitute if the original reviewer is not available).

If the adverse determination is upheld after reconsideration, Atlantis Health Plan will issue a written notice of the adverse determination. The member, the member's designee, or the member's health care provider may then proceed to further appeal the decision using either the expedited appeal or the standard appeal, as defined below.

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