In an HMO, it is important for you to understand how to access care, especially if you are injured or ill. The decision to refer you to an in-network specialist is at the discretion of your PCP based on medical necessity. Members may not self-refer. The only exception to this policy is in regard to emergency care and OB/GYN services. Referrals are not necessary for female members to receive primary and preventive obstetric and gynecological services from an AHP OB/GYN or Certified Nurse Midwife.
In the event you as a new member upon enrollment, or a current member who needs ongoing care from a specialist may receive a standing referral.
Atlantis Health Plan, or the PCP in consultation with the Medical Director of AHP and a specialist, may determine a standing referral to a specialist is appropriate. The referral shall be made pursuant to a treatment plan approved by AHP in consultation with the PCP, specialist and the member or member’s designee.
You may not elect to use a non-participating specialist unless there is no specialist in the AHP network. The treatment plan may limit the number of visits or the period during which such visits are authorized and may require regular updates to your PCP on the specialty care.
If you have such a condition, it is your right to request a standing referral. A standing referral will allow you to visit your specialist directly for a specified number of visits or time periods without requiring another referral from your PCP. If your condition requires ongoing specialty care, please contact the Atlantis Health Services Department at 1-866-747-8422 or in writing at 39 Broadway, Suite 1240, New York, New York 10006. Atlantis will notify you by telephone and in writing within three business days of our decision and if approved, will provide you with the number of visits or time period that the standing referral is approved for.
In the event you 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 long period of time, may request a standing referral to an AHP Specialty Center.
Evaluation of the Member’s condition will be discussed between the AHP Medical Director and requesting provider to determine if such a referral is appropriate. The referral will be provided pursuant to a treatment plan that has been approved by the AHP Medical Director.
You, your PCP or AHP Specialist may call the AHP Utilization Department and request a referral to an AHP Specialty Care Center.
If you are dissatisfied with a specialist that you have been referred to, please contact your PCP’s office. If a change is unable to be effected by your PCP’s office, contact the AHP Member Services Department for assistance.