<< Back to table of contents
Internal Appeal Procedures
- 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 health care provider who specifically recommended the health care 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 your health care 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, 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.
- 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, as defined on the next page.
- 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.
- Retrospective review determinations involve services, which have already been delivered to you. 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. Atlantis Health Plan will assign a clinical peer reviewer other than the one who rendered the adverse determination.
<< Back to table of contents