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Pre-authorization
A. If you choose to receive In-Plan Services, your Plan Provider will be responsible for notifying Atlantis in advance of scheduling procedures that require Pre-authorization.
1. The list of procedures requiring Pre-authorization is available to Members and is updated from time to time by Atlantis. In general Pre-authorization is required for all elective inpatient admissions, all outpatient surgical procedures, certain diagnostic and treatment procedures and some medical equipment.
B. If you choose to receive Out-of-Plan Services, you will be responsible for notifying Atlantis in advance of all non-emergency hospital admissions and elective surgical procedures. Members must complete the Pre-authorization process with Atlantis prior to an elective admission to a Non-Plan hospital, or when admitted to a Plan hospital by a Non-Plan physician. Pre-authorization for inpatient services includes, all elective hospital admissions, both maternity and non-maternity, and also to facilities for hospice, mental health, rehabilitation care, and skilled nursing.
1. Pre-authorization of Hospital Inpatient Admissions- Member must complete the Atlantis Pre-authorization process in advance of an elective admission to a Non-Plan hospital or for admission to a Plan Hospital by a Non-Plan physician. A penalty of 50% of the cost of the case per each non-certified occurrence will be deducted from Atlantis’ payment.
(a) The Member must complete the Pre-authorization process seven (7) business days in advance for an elective admission.
2. Pre-authorization of Elective Surgical Out-patient Procedures- Member must complete the Atlantis Pre-authorization process seven (7) business days in advance of an elective ambulatory surgical procedure or a penalty of 50% of the cost of the case per each noncertified occurrence will be deducted from Atlantis’ payment.
3. Notification of Emergency Admissions
(a) This Notification procedure applies to admissions, both non-maternity and maternity, and to facilities including, but not limited to hospice, mental health, rehabilitation care and skilled nursing.
(b) Member must notify Atlantis within two (2) business days or a soon as practical of an Emergency Admission to a Non-Plan hospital or an Emergency Admission to a Plan hospital by a Non-Plan physician.