Should your Primary Care Provider determine that you require specialty services, you will get a written referral to a participating AHP specialist. This form contains authorization for you to be treated, as well as information for the specialist about your condition. After you receive services, the specialist then uses the form to bill AHP for payment. The referral is valid for up to ninety (90) days as long as you are an AHP member, and can only be used for the service indicated on the form. Should you need additional treatment or tests, another referral form must be obtained from your PCP. In this way, your Primary Care Provider can assure that you are always receiving the most appropriate, medically necessary care, and you will be covered one hundred percent (100%) for the referred services you receive, after payment of the applicable copayment.
As a new Member upon enrollment, or a current member upon diagnosis with a life-threatening condition or disease or a degenerative and disabling condition or disease, either of which requires specialized care over a prolonged period of time, you may request to elect an AHP Specialist as your PCP. As the designated Specialist/PCP, he/she will be responsible for providing and coordinating all of your primary and specialty care. The Specialist will be able to order tests, arrange procedures and provide referrals and medical services in the same capacity as a PCP.
To become a Specialist/PCP, he/she must have the necessary qualifications and expertise to treat your condition or disease. This election will be permitted only if the AHP Medical Director, after consulting with both your Specialist and your original PCP agree that your care would most appropriately be coordinated in this manner.
You, the Specialist, and/or your original PCP may call the Atlantis Utilization Management Department and request this election.
There may be instances when you will disagree with a provider's recommended course of treatment or surgical recommendation. In such cases, you may receive a second opinion or second surgical opinion from another Network provider. You must pay the normal office visit copayment for second opinions that you request.
If the first opinion concerns a diagnosis of cancer (either negative or positive) or a recurrence of cancer or a recommendation for a course of treatment for cancer, you may request a referral to a non-Network specialist for a second opinion, including a specialist affiliated with a specialty care center for the treatment of cancer. This visit will be provided at no additional cost beyond the normal office visit copayment.
In some instances, we may require a second opinion before pre-authorizing certain procedures. There is no cost to you when we request a second opinion.
You, the Specialist, and/or your original PCP may call the Atlantis Utilization Management Department to request a second opinion.