Frequently Asked Questions for Member Services

1. When will I receive my ID card?
2. I have lost my ID card. How can I get a replacement?
3. How long does it take to process a medical claim?
4. I am not supposed to receive medical claims\bills. Why am I receiving a claim\bill?
5. If I change my Primary Care Physician, when will the change be effective?
6. When do I have to pay my co-payments
7. Where should my provider mail my claim?
8. What are my benefits?
9. Which services are excluded?
10. Where do I go for lab work, x-rays, durable medical equipment, etc?
11. If I have a medical emergency outside of the service area, will Atlantis Health Plan cover me?
12. What are my rights?
13. How can I appeal a decision?
14. What is Atlantis Health Plan’s grievance process?

Once Atlantis Health Plan has received your enrollment information from your employer, including your physician selection, our Enrollment Department will enter your information into our database. You will receive your ID card within seven to ten business days after the information is entered into our database.

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Should you need to replace an ID card, please call our Member Service Department at 1-866-747-8422. More information about ID cards can be found on page 4 of our Member Services Handbook.

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Normal processing of a medical claim is within 45 days of the receipt of the claim. However, additional information may be needed from the provider in order to process the claim.

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You may receive a claim if the provider of service does not have your correct insurance information. Always present your Atlantis Health Plan ID card when receiving services. Should you receive a bill which you feel is Atlantis Health Plan’s financial responsibility, please send it to us clearly marked with your name and Atlantis Health Plan ID for payment consideration to:

Atlantis Health Plan, Inc.
Member Claims
39 Broadway, Suite 1240
New York, New York 10006

More information about our medical claims submission and processing procedures can be found on pages 16 - 17 of our Member Services manual.

Be sure the bill contains the name and address of the provider of services, the nature of the service and the date and amount billed for each service.

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A Primary Care Physician change is effective immediately. You can request a change in Primary Care Physician by calling our Member Services Department. More information about choices of Primary Care Physician can be found on page 7 of our Member Services manual.

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You will be responsible for co-payments for certain professional and\or institutional services. A co-payment is a portion of the cost of the service that you are responsible for at the time the service is received. Please refer to the Summary of Benefits in your Atlantis Health Plan Subscriber Contract for all applicable co-payments.

Co-payments for professional services apply to most “visits” to a physician or other provider. The amount of the co-payment is based upon the benefit plan in which you are enrolled and the medical services received. Co-payments are on a “per visit” basis so that a visit to a provider that involves more than one service, for example, a visit to an OB\GYN that involves lab tests, will only be subject to a single co-payment.

Co-payments are not applicable to services that do not involve a visit, for example, ambulance and durable medical equipment. Co-payments for inpatient hospital services are per “continuous confinement”. A continuous hospital confinement means consecutive days as an inpatient, or successive confinements when discharge and readmission occurs within a period of not more than ninety (90) days. More information about co-payments can be found on page 14 of our Member Handbook.

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Please send all claims to:

Atlantis Health Plan
Claims Processing Department
PO Box 4656
Houston, TX 77210-4656

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Atlantis Health Plan provides a Summary of Benefits for each employer at the time of enrollment. Your Subscriber Contract gives you a more detailed description of your benefits. Should you require further clarification of your coverage, you may contact our Member Service Department at 1-866-747-8422.

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Please refer to the Restriction, Exclusions and Limitations section of your Atlantis Health Plan Subscriber Contract for a complete description or by calling our Member Service Department. More information about services can be found on page 15 of our Member Handbook.

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Your Primary Care Physician should refer you for these types of services. Your Primary Care Physician has a listing of all providers affiliated with our network and can direct you to the correct provider. If your Primary Care Physician is unsure as to where to send you, they should contact our Member Service Department for a listing.

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As an Atlantis Health Plan member, you are covered for emergency care, for as long as the emergency exists, even if the emergency happens outside of the service area. More information about medical emergencies can be found on page 8 of our Member Handbook.

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As an Atlantis Health Plan Member, you have the following RIGHTS AND RESPONSIBILITIES:

1. To obtain complete, current information concerning a diagnosis, treatment and prognosis from a physician or other provider in terms that you can be reasonably expected to understand. When it is not advisable to give such information to the Member, the information will be made available to an appropriate person on the Member’s behalf;
2. To receive information from a physician or other provider necessary to give informed consent prior to the start of any procedure or treatment; and to refuse treatment to the extent permitted by law and to be informed of the medical consequences of that action.
3. To participate in decisions relating to your healthcare. Working with your doctor, you can decide whether to accept or reject proposed medical treatments. That right extends to situations where, because of your medical condition, you are unable to communicate with your doctor or the hospital. This is done by the creation of an Advance Directive.

As a Member or Prospective Member, you also have the RIGHT to request AHP to provide:

1. A list of the names, business addresses and official positions of the board of directors, controlling persons, owners or partners of the health maintenance organization
2. A copy of the most recent annual AHP certified financial statement, including a balance sheet and summary of receipts and disbursements prepared by a certified public accountant;
3. A copy of the most recent individual, Direct Pay Subscriber Contracts;
4. Information relating to consumer complaints compiled pursuant to section two hundred of the insurance law;
5. AHP procedures for protecting the confidentiality of medical records and other Member information;
6. To inspect drug formularies, if used by AHP, and obtain information on whether individual drugs are included or excluded from coverage;
7. A written description of the quality assurance procedures used by AHP;
8. A description of the procedures followed by AHP in making decisions about the experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;
9. A list of individual health practitioner affiliations with Participating Hospitals, if any;
10. Specific written clinical review criteria relating to a particular condition or disease and, where appropriate, other clinical information which AHP might consider in our utilization review, along with how it will be used in the utilization review process, provided, however, that the information is only used by you in evaluating the Covered Services provided by AHP;
11. A copy of the application procedures and minimum qualification requirements for healthcare providers to be considered by AHP; and
12. Other information as required by the New York State Insurance Commissioner provided that such requirements are promulgated pursuant to the state administrative procedure act

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Adverse determinations will only be made by a clinical peer reviewer of AHP when requested health services or a level of care are denied because they fail to meet the established written utilization review criteria of the plan for medical necessity and appropriateness of the level of care.

A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice medicine, or a healthcare professional other than a licensed physician who, where applicable, possesses a current and valid non-restricted license, certification or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession and is in the same profession/specialty as the healthcare provider who typically manages the medical condition.

Notices of adverse determination are made in writing and include:

• The reasons for the determination
• The clinical rationale, if any,
• Instructions on how to initiate an appeal
• Notice of availability of the clinical review criteria upon which the determination was based, upon request of the member or the member’s designee,
• Specification of any additional information which should be provided to, or obtained by the plan in order to render a decision on the appeal. As a member you have the right to designate a representative to file an appeal. Only qualified clinical personnel will review appeals.

You, your designee, or your healthcare provider may request from AHP a reconsideration or appeal of the adverse determination. Various types of appeals and time frames for responses are provided for, depending on the following circumstances under which the adverse determination was made:

• Reconsideration within one (1) business day of receipt of the request;
• Expedited appeal with access to a clinical peer reviewer within one (1) business day and a determination completed in two (2) business days of receipt of necessary information to conduct the appeal.
• Standard appeal with a determination completed within sixty (60) days of receipt of necessary information to conduct the appeal. AHP will issue written notification of the appeal determination within two (2) business days.
• Retrospective review determination is made within thirty (30) days of receipt of necessary information with which to render the decision. Failure by AHP to make an appeal determination within the applicable time periods set forth in Article 49 of the Public Health Law shall be deemed to be a reversal of AHP’s initial adverse determination.

Internal Appeal Procedures

1. Except in cases of adverse determinations made during retrospective review, when an adverse determination is made without attempting to discuss the plan of care with the healthcare provider who specifically recommended the healthcare service, procedure or treatment under review, the provider may request a reconsideration of the adverse determination.

Reconsideration will occur within one (1) business day of receipt of the request, and will be conducted between the member’s healthcare 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, AHP will issue a written notice of adverse determination within one (1) business day after the determination. The member or the member’s designee or the member’s healthcare provider may then proceed to further appeal the decision using either the expedited appeal or the standard appeal, as defined below.

2. Except in cases of adverse determinations made during retrospective review, an Expedited Appeal is allowed in situations involving:

a. Continued or extended healthcare services, procedures or treatments or additional services for a member undergoing a course of continued treatment prescribed by a healthcare provider;

b. The healthcare provider believes an immediate appeal is warranted. AHP will provide the member’s healthcare provider with reasonable access within one (1) business day of receiving notice of the taking of an expedited appeal, to a clinical peer reviewer other than the clinical peer reviewer who rendered the adverse determination.

The clinical peer reviewer will render a determination within two (2) business days of receipt of necessary information to conduct the appeal.

Expedited appeals, which do not result in a resolution satisfactory to the appealing party, may be further appealed through the standard appeal process, as defined below, or a request can be made for an external appeal (refer to page 21–External Appeal Procedure)

3. Except in cases of adverse determinations made during retrospective review, a Standard Appeal process is required in all other situations than those described above.

These appeals may be filed in writing or by telephone. To file a standard appeal of an adverse determination, an appealing party has no less than forty-five (45) days after the member receives a notice of adverse determination and AHP receives all necessary information to conduct the appeal.

AHP will send written acknowledgment of receipt of the appeal to the appealing party within fifteen (15) days of the date of the appeal. AHP will assign a clinical peer reviewer other than the one who rendered the adverse determination, and the appeal determination will be rendered within sixty (60) days of receipt of information necessary to conduct the appeal.

Thereafter, AHP will issue written notification of the appeal determination within two (2) business days to the member, the member’s designee and the member’s healthcare provider. This notice will include reasons for the determination, with the clinical rationale provided where the adverse determination is upheld on the appeal and notice of the member’s right to external appeal and the timeframes for such external appeals.

4. Retrospective review determinations involve services, which have already been delivered to the member. An appeal or reconsideration of adverse determinations of this type will comply with the procedures of the standard appeal except that the appeal determination must be made within thirty (30) days of receipt of information necessary to conduct the appeal. AHP will assign a clinical peer reviewer other than the one who rendered the adverse determination.

External Appeal Procedure

You may file an application for an external appeal by a state approved external appeal agent if you have received a denial of coverage based on medical necessity or because the service is experimental and/or investigational.

To be eligible for an external appeal, you must have received a final adverse determination (FAD) as a result of AHP’s first-level utilization review (UR) appeal process or both you and AHP must jointly agree to waive the UR appeal process. An external appeal application will be attached to the FAD that you receive from the Plan.

The application will provide clear instructions for completion. You must include $50.00 with the application. Your healthcare provider may not charge you for this fee. This money will be refunded if the external appeal is decided in your favor. You may obtain a waiver of this fee if you meet AHP’s criteria for a hardship exemption. To apply for this exemption, please call our Member Services Department at 866-747-8422.

The external appeal application will instruct you to send the completed form to the New York State Department of Insurance. You (and your doctors) must release all pertinent medical information concerning your medical condition and request for services. An independent external appeal agent approved by the State will review your request to determine if the denied service is medically necessary and should be covered by AHP. All external appeals are conducted by clinical peer reviewers certified by the State. The agent’s decision is final and binding on both you and AHP.

The application for external appeal must be made within forty-five (45) days of your receipt of the notice of final adverse determination as a result of AHP’s first-level appeal process, or within forty-five (45) days of when you and AHP jointly agree to waive the internal appeal process. The Plan does not require you to exhaust the second level of appeal to be eligible for external appeal.

However, regardless of whether you participate in this additional AHP internal appeal process, an application for external appeal must be filed with the New York State Department of Insurance within forty-five (45) days from your receipt of the notice of final adverse determination from AHP’s first-level appeal to be eligible.

You will lose your right to an external appeal if you do not file an application for an external appeal within forty-five (45) days from your receipt of the final adverse determination from the first level internal plan appeal.

An external appeal agent must decide a standard appeal within thirty (30) days of receiving your application for external appeal from the state. Five (5) additional business days may be added if the agent needs additional information. If the agent determines that the information submitted to it is materially different from that considered by AHP, AHP will have three (3) additional business days to reconsider or affirm its decision. You and AHP will be notified within two (2) business days of the agent’s decision. You may request an expedited appeal if your doctor can attest that a delay in providing the recommended treatment would pose an imminent or serious threat to your health. The external appeal agent will make a decision within three days for expedited appeals. Every reasonable effort will be made to notify you and AHP of the decision by telephone or fax immediately. This will be followed immediately by a written notice.

In the event an adverse determination is overturned on external appeal, or in the event that AHP reverses a denial, which is the subject of external appeal, AHP shall provide or arrange to provide the healthcare service(s), which is the basis of the external appeal to you.

If you are no longer insured by AHP at the time of an external appeal agent’s reversal of AHP’s utilization review denial, AHP will not be required to provide any healthcare services to you. You, your designee or your healthcare provider, may request an external appeal of a retrospective adverse determination if the services in question were denied based on medical necessity and/or were considered experimental and/or investigational.

Contact Information for External Appeals:

• The New York State Department of Insurance at 800-400-8882, or its website (www.ins.state.ny.us)
• The New York State Department of Health website only (www.health.state.ny.us) or
• Our Member Services Department at 866-747-8422.

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AHP attempts to solve your problems or complaints through the Member Services Department in an efficient manner. You may file a complaint or grievance regarding services provided by Atlantis Health Plan (AHP) or a contracted practitioner and/or facility, denial of access to a referral, a requested benefit that is not covered pursuant to the contract provisions, or concerning the professional and/or business conduct of AHP, employees, contracted practitioners and/or their employees or personnel. A member may also submit a verbal or written request to review an adverse determination concerning an administrative decision not related to medical necessity, for example, the processing and payment of a claim, balance billing etc. AHP has established the following grievance policy and procedure for use by its members.

1. For purposes of clarity, the term grievance or complaint may be used interchangeably.
2. Qualified clinical personnel will make determination of all complaints involving clinical decisions.
3. AHP will allow only qualified personnel to make determinations with regard to the provision of your benefits. Any denial will be accompanied by an explanation and a basis behind the decision and further appeal rights.
4. AHP will not retaliate or take any discriminatory action against the member because they filed a complaint or appeal.
5. The member has the right to designate a representative to file complaints and appeals on his behalf. Any member who wants to access the grievance process, but is unable to put his/her grievance into writing due to a disability and/or lack of literacy may contact the AHP Member Service department. The Member Service Representative will then document the member’s grievance. In the event, a non-English speaking member files a grievance, AHP will arrange to have an interpreter available.
6. The member has a right to file a complaint verbally when the dispute is about referrals or covered benefits. To file a complaint verbally, please call AHP Member Services Department at 866-747-8422. To send a written grievance or a complaint, please address your letter to:

   Atlantis Health Plan, Grievance Dept.
   39 Broadway, Suite 1240,
   New York, NY, 10006

   Members may contact the State Insurance or Health Department at any time during the complaint process. Listed below are the toll-free telephone numbers for each Agency.

   New York State Department of Health
   800-206-8125
   90 Church Street
   New York, New York 10007

   New York State Department of Insurance, Consumer Services Unit
   800-342-3736
   160 West Broadway
   New York, New York 10013

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