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 need a referral from my Primary Care Physician?
7. When do I have to pay my copayments?
8. Where should my provider mail my claim?
9. What are my benefits?
10. Which services are excluded?
11. Where do I go for lab work, x-rays, durable medical equipment, etc?
12. If I have a medical emergency outside of the service area, will Atlantis Health Plan cover me?
13. What are my rights?
14. How can I appeal a decision?
15. 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 replacement ID card, please call our Member Service Department at 1-877-MD-ASSIST. More information about ID cards can be found on page 3 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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Your Primary Care Physician manages all aspects of your healthcare. When your Primary Care Physician deems it medically necessary, he/she may refer you to an in-network specialist for services. You should obtain a referral form your Primary Care Physician prior to: seeing a specialist, obtaining durable medical equipment, outpatient services, or going to an Urgent Care Center or Emergency Room for non-life threatening conditions.

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You will be responsible for copayments for certain professional and\or institutional services. A copayment 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 copayments.

Copayments for professional services apply to most �visits� to a physician or other provider. The amount of the copayment is based upon the benefit plan in which you are enrolled and the medical services received. Copayments 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 copayment.

Copayments are not applicable to services that do not involve a visit, for example, ambulance and durable medical equipment. Copayments 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 copayments can be found on page 16 of our Member Services manual.

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The address for submitting claims is on the back of your ID card.

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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 1-877- MD- ASSIST (877) 632-7747.

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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 17 of our Member Services manual.

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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 11 of our Member Services manual.

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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 you, the information will be made available to an appropriate person on your 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 health care. 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 Atlantis Health Plan 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 Atlantis Health Plan 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 (200) of the insurance law;
5. Atlantis Health Plan procedures for protecting the confidentiality of medical records and other member information;
6. To inspect drug formularies, if used by Atlantis Health Plan, and obtain information on whether individual drugs are included or excluded from coverage;
7. A written description of the quality assurance procedures used by Atlantis Health Plan;
8. A description of the procedures followed by Atlantis Health Plan 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 Atlantis Health Plan 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 Atlantis Health Plan;
11. A copy of the application procedures and minimum qualification requirements for health care providers to be considered by Atlantis Health Plan; 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 Atlantis Health Plan 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 health care 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 health care 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 you or the your designee
• specification of any additional information which should be provided to, or obtained by, Atlantis Health 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 health care provider may request from Atlantis Health Plan an 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:

• 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. Atlantis Health Plan 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 Atlantis Health Plan 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 Atlantis Health Plan's initial adverse determination.

INTERNAL APPEAL PROCEDURES

If the adverse determination is upheld after reconsideration, Atlantis Health Plan will issue a written notice of adverse determination within one (1) business day after the determination. You, your designee or your health care provider may then proceed to further appeal the decision using either the expedited appeal or the standard appeal, as defined below.

1. Except in cases of adverse determinations made during retrospective review, an Expedited Appeal is allowed in situations involving:
   • continued or extended health care services, procedures or treatments or additional services for a member undergoing a course of continued treatment prescribed by a health care provider;
   • the health care provider believes an immediate appeal is warranted.

   Atlantis Health Plan will provide your health care 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.

2. 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 you receive a notice of adverse determination and Atlantis Health Plan receives all necessary information to conduct the appeal.

   Atlantis Health Plan will send written acknowledgment of receipt of the appeal to the appealing party within fifteen (15) days of the date of the appeal. Atlantis Health Plan 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, Atlantis Health Plan will issue written notification of the appeal determination within two (2) business days to you, your designee and your health care provider. This notice will include reasons for the determination, with the clinical rationale provided where the adverse determination is upheld on the appeal.

3. Retrospective review determinations involve services, which have already been delivered to you. An appeal 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. Atlantis Health Plan 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 as a result of Atlantis Health Plan's first-level utilization review (UR) appeal process or both you and Atlantis Health Plan must jointly agree to waive the UR appeal process.

You may obtain an external appeal application from:

• The New York State Department of Insurance at 1-800-400-8882, or its website (www.ins.state.ny.us), or
• Atlantis Member Services Department at 1-877-MD-ASSIST (632-7747).

The application will provide clear instructions for completion. To file an external appeal, you must include $50.00 with the application. 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 Atlantis Health Plan's criteria for a hardship exemption.

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 Atlantis Health Plan's first-level appeal process, or within forty-five (45) days of when you and Atlantis Health Plan jointly agree to waive the internal appeal process. Additional internal Atlantis Health Plan appeals are available to you which are optional.

However, regardless of whether you participate in additional Atlantis Health Plan internal appeals, 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 Atlantis Health Plan's first-level appeal to be eligible to be reviewed by an external appeal agent.

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.

The application will instruct you to send it 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 Atlantis Health Plan. All external appeals are conducted by clinical peer reviewers. The agent's decision is final and binding on both you and Atlantis Health Plan.

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 Atlantis Health Plan, Atlantis Health Plan will have three (3) additional business days to reconsider or affirm its decision. You and Atlantis Health Plan 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 (3) days for expedited appeals. Every reasonable effort will be made to notify you and Atlantis Health Plan of the decision by telephone or fax immediately. This will be followed immediately by a written notice.

Your health care 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.

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

If you are no longer insured by Atlantis Health Plan at the time of an external appeal agent's reversal of Atlantis Health Plan's utilization review denial, Atlantis Health Plan will not be required to provide any health care services to you.

To request an application for an external appeal, your health care provider may contact Atlantis Health Plan at 1-877-MD-ASSIST (632-7747), Atlantis Health Plan will send your health care provider the application within three (3) business days from the date we receive his/her request for the application. The application will provide clear instructions for completion. To file an external appeal, he/she must include $50.00 with the application. This money will be refunded if the external appeal agent overturns Atlantis Health Plan's adverse determination. Your health care provider may not charge you, the member for this fee.

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Atlantis Health Plan attempts to solve your problems or complaints through the Member Services Department in an efficient manner. Atlantis Health Plan has established the following grievance procedures for use by Members who are in any way dissatisfied with Atlantis Health Plan or a participating provider.

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: 1-800-206-8125
New York State Department of Insurance: 1-800-342-3736
Consumer Services Unit
160 West Broadway
New York, New York 10013

Members with complaints should call the Atlantis Health Plan Member Services Department at 1 (877) MD-ASSIST, or write to: Atlantis Health Plan, Member Services Dept., 39 Broadway, Suite 1240, New York, NY, 10006. Atlantis Health Plan will send written acknowledgement of receipt of the complaint to the complaining party within fifteen (15) days of the date of the complaint. Each complaint will be promptly investigated and Atlantis Health Plan will provide a Member with a response to a complaint within thirty (30) days of receipt of all necessary information for disputes involving your contract benefits and forty-five (45) days for all other disputes. If your health is in danger, then Atlantis Health Plan will give a response within forty-eight (48) hours or two (2) days. This response will be a written notice of complaint determination, which will include information about the basis of the decision, the your right to appeal and the appeal procedure.

If you are dissatisfied with the Plan's handling of a complaint or receive a claim denial from Atlantis Health Plan, you may file a Grievance. To make this process more accessible to non-English speaking members, Atlantis Health Plan can arrange to have an interpreter available who speaks your language. You also have the right to file a complaint orally when your dispute is about referrals or covered benefits.

The following policies apply to the filing of a complaint or Grievance:

1. You have the right to file a complaint regarding any dispute with Atlantis Health Plan.
2. Qualified clinical personnel will make determination of all clinical complaints involving clinical decisions.
3. Atlantis Health Plan will allow only qualified clinical 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. Atlantis Health Plan will not retaliate or take any discriminatory action against you because you filed a complaint or appeal.
5. You have the right to designate a representative to file complaints and appeals on your behalf.
6. You have the right to file a complaint verbally when the dispute is about referrals or covered benefits.

The following timeframes apply to the Grievance Procedure:

1. You or your designee has no less than 60 business days after receipt of the notice of the complaint determination to file a written appeal.
2. Grievance appeals may be submitted in writing, on a form provided by Atlantis Health Plan or verbally.
3. Within fifteen (15) business days of receipt of the appeal, Atlantis Health Plan shall provide written acknowledgment including the name; address and telephone number of the individual designated to respond to the appeal. Atlantis Health Plan will indicate what additional information, if any must be provided for Atlantis Health Plan to render a decision.
4. Personnel qualified to review the complaint, including licensed, certified or registered health care professionals who did not make the initial determination will decide grievance appeals related to clinical matters.
5. Qualified personnel at a higher level than the personnel who made the original complaint determination will make grievance appeal determinations of non-clinical matters.
6. Appeals will be decided and notification provided to you no more than:
   • Two (2) business days after the receipt of all necessary information when a delay would significantly increase the risk to your health.
   • Thirty (30) business days after the receipt of all necessary information in all other instances.
7. The written notice of an appeal determination will include the detailed reasons for the determination, the clinical rationale if applicable, and instructions for any other appeal.

The notice will also inform you of your right to contact the State Insurance or Health Department at any time during the complaint process.

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