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Referral/Authorization Summary Sheet

FOR ALL MEMBERS, IN-NETWORK SERVICES ENTAIL THE LOWEST OUT-OF-POCKET EXPENSES

Procedures/Services NOT requiring pre-authorization or written referral:

PCP Office Visit
OB/GYN Office Visit
Routine Vision Care
Mammography
Prescription /Pharmaceutical Services (exception list attached)
Routine Radiology Services (plain films)
Laboratory services

Procedures/Services requiring written referrals:

A written referral is issued for consultation, diagnosis, or treatment
Referrals are valid for ninety (90) days from the date of the requesting provider's signature
Fill in the complete name and identification number for the member; include the member's medication and allergy history
Include a rule out or working diagnosis
Fill in the Specialist's name*
PCP must sign and date the referral
Send white & pink copies and any relevant attachments to the specialist
PCP is to retain the green copy for his/her records

*Refer to the Atlantis Health Plan Provider Directory for a listing of participating network specialists. Please call the Atlantis Health Plan Utilization Department at 1-800-270-9072 if there are no providers listed for a particular specialty. Health Plan policyholders require pre-authorization for out-of-network referrals. For all members, in-network referrals entail the lowest out-of-pocket expense

Services requiring Plan notification (1-800-270-9072):

Urgent inpatient admissions
Emergency inpatient admissions
Emergency Room services within forty-eight (48) hours of treatment

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