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Member Services Department
Atlantis Health Plan's Member Services Representatives are available to answer any questions you may have about Atlantis Health Plan. Please call us to request an additional identification card, change Primary Care Physicians, report an emergency or request clarification on a particular benefit.
Call Atlantis Health Plan's Member Services Department: at 1-877-MD-ASSIST or you may FAX us at (212) 747-0843.
If you prefer to contact us in writing, please send all correspondence to:
Atlantis Health Plan, Inc. Member Services
The Grievance Process
39 Broadway, Suite 1240
New York, New York 10006
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.
You 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
Members with complaints should call the Atlantis Health Plan Member Services Department at 1-877-MD-ASSIST, or write to: Atlantis Health Plan, Inc., Member Services Dept., l I Broadway, Suite 1240, New York, NY, 10006. Atlantis Health Plan will send written acknowledgement of receipt of the complaint to the complaining patty within fifteen (15) days of the date of the complaint. Each complaint will be promptly investigated and Atlantis Health Plan will provide you 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, your right to appeal and the appeal procedure.
New York State Department of Insurance: 1-800-342-3736
Consumer Services Unit
160 West Broadway
New York, New York 10013
If you are dissatisfied with Atlantis Health 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:
The following timeframes apply to the Grievance Procedure:
- You have the right to file a complaint regarding any dispute with Atlantis Health Plan.
- Qualified clinical personnel will make determination of all clinical complaints involving clinical decisions.
- 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.
- Atlantis Health Plan will not retaliate or take any discriminatory action against you because you filed a complaint or appeal.
- You have the right to designate a representative to file complaints and appeals on your behalf.
- You have the right to file a complaint verbally when the dispute is about referrals or covered benefits.
- You or your designee has no less than sixty (60) business days after receipt of the notice of the complaint determination to file a written appeal.
- Grievance appeals may be submitted in writing, on a form provided by Atlantis Health Plan or verbally.
- 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.
- 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.
- Qualified personnel at a higher level than the personnel who made the original complaint determination will make grievance appeal determinations of non-clinical matters.
- 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.
- 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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