Atlantis Health Plan Member Handbook- POS
Pre-authorization is necessary for any hospital admission and/or outpatient surgery you may need, unless you are admitted on an emergency basis.
When using In-Plan benefits for elective hospital services, you will be admitted to the hospital where your Primary Care Provider or referred specialist is affiliated. All non-emergency hospital admissions must be pre-authorized by AHP and your Primary Care Provider. The participating provider will contact Atlantis for pre-authorization. All appropriately referred and pre-authorized hospital services are covered one hundred percent (100%), after payment of the required copayment.
If you are admitted to a non-participating hospital because of an emergency, you may be transferred, at no additional cost to you, to an AHP participating hospital when you are well enough, so that your AHP doctor can treat you.
When using Out-of-Plan benefits, you must contact Atlantis in advance of any elective ambulatory surgery or proposed hospital admission. Failure to pre-authorize these services will result in a 10% reduction in benefits.
If your medical situation is not an emergency but still requires urgent medical attention:
Call your Primary Care Provider. Your PCP has agreed to be available to you for urgent care, personally or through another participating AHP physician, twenty-four (24) hours a day, seven (7) days a week. These hours include holidays. Be sure to call during normal office hours for routine situations, and only call after hours, in URGENT situations. If necessary, leave a message with the answering service, and the doctor will return your call.
WHAT IS A MEDICAL EMERGENCY?
placing the health of the afflicted Member with such condition in serious jeopardy, or, in the case of a behavioral condition, placing the health of such Member or others in serious jeopardy; serious impairment to the Member's bodily functions; serious dysfunction of any bodily organ or part of such Member; or serious disfigurement of such Member.
Some examples of Medical Emergencies are:
AHP covers emergency services one hundred percent (100%), after applicable copayments. The following guidelines should be followed for services to be covered.
If you believe that you or a covered family member has a medical emergency:
As an AHP member, you are covered for emergency care, for as long as the emergency exists, even if the emergency happens outside of the service area. If you have an emergency situation outside of the AHP service area, you should do the following.
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