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External Appeal Procedures

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 as 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);
Contacting the New York State Department of Health at 1-518-486-6074, or its website (www.health.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 for this fee.

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