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Atlantis Health Plan Member Handbook- POS

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HOSPITAL SERVICES

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.

URGENT CARE AFTER HOURS

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.

EMERGENCY CARE

WHAT IS A MEDICAL EMERGENCY?
A medical emergency is defined as follows: A medical or behavioral condition the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

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.

emergencies do not require prior authorization

Some examples of Medical Emergencies are:

  • Severe Chest Pains
  • Shortness of Breath
  • Loss of Consciousness
  • Uncontrolled Breathing
  • Poisoning
Some examples of situations that are usually NOT Medical Emergencies:
  • Earaches
  • Pink Eye
  • Fatigue
  • Sprains & Strains
  • Poison Ivy
  • Colds, Coughs, & Sore Throats
EMERGENCY SERVICES WITHIN THE SERVICE AREA:

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:

  • Go to the nearest hospital emergency room or call 911 if the condition warrants it.
  • Call your Primary Care Provider within forty-eight (48) hours after the emergency visit, or as soon as is reasonably possible.
  • Your PCP, or covering provider, is available for emergency consultation (24) hours a day, (7) days a week, to include holidays.
  • Your PCP will coordinate or provide follow-up care that you may require after your emergency visit. If you return to the hospital for follow-up care without a written referral from your Primary Care Provider, AHP will not be responsible for the bill.
  • If your PCP gave the emergency facility a telephone authorization for treatment, and if the emergency facility documents that authorization on your medical record, AHP will cover the service. If however, there is no documentation from your Primary Care Provider, Atlantis Health Plan will make a determination as to whether or not the situation was an emergency, based on your medical records from the emergency facility. You will be responsible for all charges for care that does not meet the definition of an emergency as stated above.
EMERGENCY SERVICES OUTSIDE OF THE SERVICE AREA:

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.

  • Seek treatment at the nearest emergency facility
  • Call your Primary Care Provider and AHP as soon as possible
  • Get a written referral for any follow-up care that needs to be provided
REMEMBER:
  • The back of your Atlantis Membership Identification card has the telephone number where emergency providers can call if there are questions about your coverage.
  • Atlantis will encourage them to bill the plan directly.
  • However, if it is necessary for you to pay for the services, and you believe that it is the responsibility of Atlantis Health Plan, please refer to the section on “Submitting Claims” in this handbook.

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