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Atlantis Health Plan Member Handbook- POS

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USING OUT-of-PLAN BENEFITS

In order to be covered In-Plan, all referral and authorization requirements must be followed. All other services, even if provided through the participating network, will be considered Out-of-Plan. All elective hospital admissions and outpatient surgical procedures require Pre-authorization. In other words, either your physician, in the case of the In-Plan benefit, or you, in the case of the Out-of-Plan benefit, must contact Atlantis in advance with regard to elective admissions and outpatient surgery.

When using Out-of-Plan benefits for elective admissions or outpatient surgical procedures, if you do not contact Atlantis in advance, you will be subject to a penalty of 50% of the cost of the service in addition to any deductible and/or coinsurance. Please note that Well-Child Care, including immunizations is only covered In-Plan.

Before electing to use Out-of-Plan benefits we recommend that you carefully review the “Summary of Benefits” for limitations, coinsurance, deductibles, annual and lifetime maximums on Out-of-Plan benefits. You are encouraged to call Member Services prior to receiving such services to verify coverage and cost sharing arrangements. Upon written request, you may also obtain the Atlantis reimbursement amount for a particular elective surgical procedure or treatment. The request should be sent to Member Services. Please provide details on the procedure, to include the procedure name, CPT code (if available) and/or your provider’s name, address and telephone number.

SUBMITTING CLAIMS

Atlantis makes payment for Medical and Hospital Services and Prescription Drugs to the provider of services or, at its sole discretion, directly to the Member. Atlantis’ liability to the Member for bills for covered services or for Prescription Drugs is limited to bills received by Atlantis within Twelve (12) months of the date of service.

With respect to In-Plan HMO services, it is not anticipated that a Member will make payment other than any applicable co-payment to any person or institution providing benefits under the Contract. If the Member furnishes evidence to Atlantis that he or she has made such other payments with respect to Services, payment will be made to the Member.

Claims for Out-of-Plan POS services should be submitted directly to Atlantis. Claims forms are available by calling Member Services at 1-866-747-8422. The completed claim should be mailed to:

Atlantis Health Plan, Inc.
Member Claims
39 Broadway, Suite 1240
New York, NY 10006
Be sure the bill contains the name and address of the provider of service, a diagnosis, and the date and amount billed for each service.

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