There may be instances when you will disagree with a provider's recommended course of treatment or surgical recommendation. In such cases, you may receive a second opinion or second surgical opinion from another Network provider. You must pay the normal office visit copayment for second opinions that you request.
If the first opinion concerns a diagnosis of cancer (either negative or positive) or a recurrence of cancer or a recommendation for a course of treatment for cancer, you may request a referral to a non-Network specialist for a second opinion, including a specialist affiliated with a specialty care center for the treatment of cancer. This visit will be provided at no additional cost beyond the normal office visit copayment.
In some instances, we may require a second opinion before pre-authorizing certain procedures. There is no cost to you when we request a second opinion. You, the Specialist, and/or your original PCP may call the Atlantis Utilization Management Department to request a second opinion.
In a Health Plan, it is important for you to understand how to access care, especially if you are injured or ill. The decision to refer you to an In-Network specialist is at the discretion of your PCP based on medical necessity. You may not self-refer. The only exception to this policy is in regard to emergency care and OB/GYN services. Referrals are not necessary for female Members to receive primary and preventive obstetric and gynecological services from an Atlantis Health Plan OB/GYN or Certified Nurse Midwife (refer to page 11 of this document).
Standing Referrals to Atlantis Health Plan Specialist You as a new Member upon enrollment, or a current Member who needs ongoing care from a specialist, may receive a standing referral to an Atlantis Health Plan Specialist.
Atlantis Health Plan, or the PCP in consultation with the Medical Director of Atlantis Health Plan and a specialist, may determine a standing referral to a specialist is appropriate. The referral shall be made pursuant to a treatment plan approved by Atlantis Health Plan in consultation with the PCP, specialist and you or your designee.
You may not elect to use a non-participating specialist unless there is no specialist in the Atlantis Health Plan network. The treatment plan may limit the number of visits or the period during which such visits are authorized and may require regular updates to your PCP on the specialty care. If you have such a condition, it is your right to request a standing referral.
A standing referral will allow you to visit your specialist directly for a specified number of visits or time period without requiring another referral from your PCP If your condition requires ongoing specialty care, please contact the Utilization Department at 1-800-270-9072 or in writing at 39 Broadway, Suite 1240, New York, New York 10006. Atlantis will notify you by telephone and in writing within three (3) business days of our decision and if approved, will provide you with the number of visits or time period that the standing referral is approved for.