Atlantis Health Plan Member Handbook- POS
Adverse determinations will only be made by a clinical peer reviewer of AHP when requested health services or a level of care are denied because they fail to meet the established written utilization review criteria of the plan for medical necessity and appropriateness of the level of care.
A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid non-restricted license, certification or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession and is in the same profession/specialty as the health care provider who typically manages the medical condition.
Notices of adverse determination are made in writing and include:
You, your designee, or your health care provider may request from AHP a reconsideration or appeal of the adverse determination. Various types of appeals and time frames for responses are provided for, depending on the following circumstances under which the adverse determination was made:
INTERNAL APPEAL PROCEDURES
You may file an application for an external appeal by a state approved external appeal agent if you have received a denial of coverage based on medical necessity or because the service is experimental and/or investigational.
To be eligible for an external appeal, you must have received a final adverse determination as a result of AHP�s first-level utilization review (UR) appeal process or both you and AHP must jointly agree to waive the UR appeal process.
You may obtain an external appeal application from:
The application will provide clear instructions for completion. To file an external appeal, you must include $50.00 with the application. This money will be refunded if the external appeal is decided in your favor. You may obtain a waiver of this fee if you meet AHP�s criteria for a hardship exemption.
The application for external appeal must be made within 45 days of your receipt of the notice of final adverse determination as a result of AHP�s first-level appeal process, or within 45 days of when you and AHP jointly agree to waive the internal appeal process. Additional internal AHP appeals are available to you which are optional.
However, regardless of whether you participate in additional AHP internal appeals, an application for external appeal must be filed with the New York State Department of Insurance within 45 days from your receipt of the notice of final adverse determination from AHP�s first-level appeal to be eligible to be reviewed by an external appeal agent.
You will lose your right to an external appeal if you do not file an application for an external appeal within 45 days from your receipt of the final adverse determination from the first level internal plan appeal.The application will instruct you to send it to the New York State Department of Insurance. You (and your doctors) must release all pertinent medical information concerning your medical condition and request for services. An independent external appeal agent approved by the state will review your request to determine if the denied service is medically necessary and should be covered by AHP. All external appeals are conducted by clinical peer reviewers. The agent�s decision is final and binding on both you and AHP.
An external appeal agent must decide a standard appeal within 30 days of receiving your application for external appeal from the state. Five (5) additional business days may be added if the agent needs additional information. If the agent determines that the information submitted to it is materially different from that considered by AHP, AHP will have three (3) additional business days to reconsider or affirm its decision. You and AHP will be notified within 2 business days of the agent�s decision.
You may request an expedited appeal if your doctor can attest that a delay in providing the recommended treatment would pose an imminent or serious threat to your health. The external appeal agent will make a decision within three days for expedited appeals. Every reasonable effort will be made to notify you and AHP of the decision by telephone or fax immediately. This will be followed immediately by a written notice.
In the event an adverse determination is overturned on external appeal, or in the event that AHP reverses a denial which is the subject of external appeal, AHP shall provide or arrange to provide the health care service(s) which is the basis of the external appeal to you.
If you are no longer insured by AHP at the time of an external appeal agent�s reversal of AHP�s utilization review denial, AHP will not be required to provide any health care services to you.
You, your designee or your health care provider, may request an external appeal of a retrospective adverse determination if the services in question were denied based on medical necessity and/or were considered experimental and/or investigational.
To request an application for an external appeal, you, your designee, or your health care provider may contact AHP at 1-866-747-8422. AHP will send you, your designee, or your health care provider the application within three (3) business days from the date we receive his/her request for the application. The application will provide clear instructions for completion. To file an external appeal, he/she must include $50.00 with the application. This money will be refunded if the external appeal agent overturns AHP�s adverse determination. Your health care provider may not charge you, the member for this fee.
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