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Atlantis Health Plan Member Handbook- POS

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THE PRIMARY CARE PROVIDER

AHP believes that staying healthy requires a healthy lifestyle and a good relationship with a Primary Care Provider (PCP). When you enrolled in AHP, you were asked to select a Primary Care Provider from our list of participating health care practitioners. In general a PCP will be a General Practitioner, Family Practitioner, Internist, or Pediatrician. Selected specialists and other health care practitioners who are recognized in the community as providers of primary care may also be allowed the PCP designation.

Family Members will have their own PCP. This is not to suggest that all family Members cannot choose the same PCP, but that each member must have a PCP designated on the enrollment form.

When using In-Plan HMO benefits, the PCP that you selected will be responsible for the coordination of your health care. If you have chosen a PCP that you are not established with, contact his or her office as soon as possible in order to set up an appointment for an initial physical and/or evaluation. That way, if you become ill or injured, your PCP will already have information about you and your health history in order to make a determination regarding whether you should be seen by him or her first or immediately referred to a specialist.

Some PCPs are not accepting patients that are not already established with them. In that case, the PCP will be indicated with an asterisk (*) in the provider directory. If you have a question as to whether you are considered an established patient, or if the PCP will accept you into his or her practice, contact the PCP’s office directly.

Each time you receive care from your PCP, whether it is for a routine physical examination or for treatment of an illness or injury, your relationship will continue to grow. In addition, your Primary Care Provider will coordinate all of your other medical services.

Your Primary Care Provider will issue a referral to you when you need specialty care, or any other non-emergency medical services. In-Plan benefits are only valid when non-emergency services are referred by your Primary Care Provider. In this way, your PCP remains informed of your medical condition.

Be sure to call your Primary Care Provider’s office in advance to schedule an appointment for care. When you arrive at the office, always show your AHP identification card and pay any applicable copayment amount. Primary care services are covered one hundred percent (100%) after payment of the applicable copayment.

CHANGING YOUR PRIMARY CARE PROVIDER

If, for some reason, you want to change your Primary Care Provider, just call the toll free number on your card under Member Services and speak with a Representative. He/she will note your request or assist you in identifying a new PCP if necessary. The change will be effective immediately. Within two weeks, you will receive a new Membership Card in the mail with your new PCP's name on it. You may change your PCP up to three (3) times per contract year.

IN-PLAN SPECIALTY SERVICES

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.

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