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Atlantis Medical Group
Clinical Review Criteria
Table of Contents
Important Telephone Numbers
1.1
Introduction
1.2
Identification Card
1.2
Primary Care Provider
1.3
Changing Your Primary Care Provider
1.3
In-Plan Specialty Services
1.4
Specialist as Primary Care Physician
1.4
Second Opinions
1.4
In-Plan Referrals
1.
5
Standing Referrals to an AHP Specialist
1.
5
Referrals to an AHP Specialty Care Center
1.
5
Changing Your Specialist
1.
5
Out-of-Network Specialist Care & Specialty Centers
1.6
Transitional Care
1.
6
Hospital Services
1.
7
Urgent Care After Hours
1.7
Emergency Care
1.8
Routine Gynecological Care
1.9
Obstetrical/Maternity Care
1.
9
Hospice
1.
9
Behavioral Health Care Services
1.
10
Vision Care
1.
10
Prescription Drugs
1.
10
Chiropractic Care
1.
10
Experimental and/or Investigational Treatment or Procedures
1.
11
Informed Consent and Advance Directives
1.
11
Using Out-of-Plan Benefits
1.
12
Submitting Claims
1.
12
Covered Services
1.
13
In-Plan Copayments
1.
13
Out-of-Plan
1.
13
Out-of-Plan Coinsurance
1.
14
Out-of-Plan Service Penalties
1.
14
Out-of-Plan Benefit Maximum
1.
14
Excluded Services
1.
14
Pre-authorization
1.
15
Utilization Review
1.
15
Appeal Procedures
1.16
Member Rights & Responsibilities
1.
20
Member Service Department
1.
21
The Grievance Process
1.
21
Membership Issues
1.
23
Member Acknowledgements
1.
25
GROUP SUBSCRIBER CERTIFICATE OF COVERAGE
2.
3
Introduction
2.
7
Definitions
2.
8
Eligibility and Family Coverage
2.11
Pre-Existing Condition Limitation
2.13
In-Plan Benefits
2.14
Accessing Out-of-Plan Benefits
2.26
Restrictions, Exclusions and Limitations
2.26
Your Primary Care Provider
2.30
In-Plan Refferrals
2.31
Pre-Authorization
2.32
Utilization Review
2.33
Member Complaints and Grievances
2.34
Co-Payments, Co-Insurance and Deductibles
2.35
Claim Payments
2.36
Provider Payment Methodoligies
2.37
Coordination of Benefits
2.38
Termination of Coverage
2.40
Right to Continuation of Coverage
2.42
Member Input in the Development of Plan Policies
2.49
Consent To Release Information
2.49
General Provisions
2.50
Non-English Speaking Enrollee
2.51
PRESCRIPTION BENEFIT PROGRAM
Benefit Program Description
3.3
Partial list of participating pharmacies
3.5
Generic Drug Q&A;
3.6
