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Urgent After Care Hours
If your medical situation is not an emergency but still requires urgent medical attention:
Call your Primary Care Provider. Your PCP has agreed to be available to you for urgent care, personally or through another participating Atlantis Health Plan physician, twenty-four (24) hours a day, seven (7) days a week, including holidays. Be sure to call during normal office hours for routine situations, and only call after hours, in URGENT situations. If necessary, leave a message with the answering service, and the doctor will return your call.
WHAT IS A MEDICAL EMERGENCY?
A medical emergency is defined as follows: A medical or behavioral condition the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:
True emergencies do not require prior authorization.
- placing your health with such condition in serious jeopardy, or, in the case of a behavioral condition, placing your health or others' in serious jeopardy;
- serious impairment to your bodily functions;
- serious dysfunction of any bodily organ or part; or
- serious disfigurement.
Some examples of Medical Emergencies:
Some examples of situations that are usually NOT Medical Emergencies:
- Loss of Consciousness
- Severe Chest Pains
- Uncontrolled Breathing
- Shortness of Breath
EMERGENCY SERVICES WITHIN THE SERVICE AREA:
- Colds, Coughs, & Sore Throats
- Pink Eye
- Poison Ivy
- Sprains & Strains
Atlantis Health Plan covers emergency services one hundred percent (100%), after applicable copayments. The following guidelines should be followed for services to be covered.
If you believe that you or a covered family Member has a medical emergency:
- Go to the nearest hospital emergency room or call 911 if the condition warrants it.
- Call your Primary Care Provider within forty-eight (48) hours after the emergency visit, or as soon as is reasonably possible.
EMERGENCY SERVICES OUTSIDE OF THE SERVICE AREA:
- Your PCP, or covering provider, is available for emergency consultation twenty-four (24) hours a day, seven (7) days a week, including holiday.
- Your PCP will coordinate or provide follow-up care that you may require after your emergency visit. If you return to the hospital for follow-up care without a written referral from your Primary Care Provider Atlantis Health Plan will not be responsible for the bill.
- If your PCP gave the emergency facility a telephone authorization for treatment, and if the emergency facility documents that authorization on your medical record, Atlantis Health Plan will cover the service. If however, there is no documentation from your Primary Care Provider, Atlantis Health Plan will make a determination as to whether or not the situation was an emergency, based on your medical records from the' emergency facility. You will be _responsible for all charges for care that does not meet the definition of an emergency as stated above.
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. If you have an emergency situation outside of the Atlantis Health Plan service area, you should do the following:
- Seek treatment at the nearest emergency facility
- Call your Primary Care Provider and Atlantis Health Plan as soon as possible
- Get a written referral for any follow-up care that needs to be provided.
- The back of your Atlantis Membership Identification card has the telephone number where emergency providers can call if there are questions about your coverage
- Atlantis will encourage them to bill Atlantis Health Plan directly
- However, if it is necessary for you to pay for the services, and you believe that it is the responsibility of Atlantis Health Plan, please refer to the section on "Submitting Claims" on page 15 in this handbook.
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