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Atlantis Health Plan Member Handbook- POS

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MEMBER SERVICES DEPARTMENT

AHP's Member Services Representatives are available to answer any questions you may have about the Plan. Please call us to request an additional identification card, change primary care physicians, report an emergency or request clarification on a particular benefit.

Call AHP's Member Services Department: at 1-866-747-8422 or you may FAX us at 1-212-747-0843

If you prefer to contact us in writing, please send all correspondence to:

Atlantis Health Plan
Member Services
39 Broadway, Suite 1240
New York, New York 10006
THE GRIEVANCE PROCESS

AHP attempts to solve your problems or complaints through the Member Services Department in an efficient manner. AHP has established the following grievance procedures for use by members who are in any way dissatisfied with AHP or a participating provider.

Members may contact the State Insurance or Health Department at any time during the complaint process. Listed below are the toll-free telephone numbers for each Agency.

New York State Department of Health
Office of Managed Care
Corning Tower Building 19th Fl.
Albany, New York 12237
      1-800-206-8125
New York State Department of Insurance
Consumer Services Unit
160 West Broadway
New York, New York 10013
      1-800-342-3736

Members with complaints should call the AHP Member Services Department at 1 (866) 747-8422, or write to: Atlantis Health Plan, Member Services Dept., 39 Broadway, Suite 1240, New York, NY, 10006. Each complaint will be promptly investigated and AHP will provide a member with a response to a complaint within thirty (30) days of receipt of all necessary information in the case of requests for referrals and\or for disputes involving member contract benefits and forty-five (45) days for all other disputes. If a memberís health is in danger, then AHP will give a response within forty-eight (48) hours or two (2) days. This response will be a written notice of complaint determination, which will include information about the basis of the decision, the memberís right to appeal and the appeal procedure.

Members who are dissatisfied with the Plan's handling of a complaint or who receive a claim denial from AHP, may file a Grievance. To make this process more accessible to non-English speaking members, AHP can arrange to have an interpreter available who speaks your language. You also have the right to file a complaint orally when your dispute is about referrals or covered benefits.

The following policies apply to the filing of a complaint or Grievance/Appeal:

  • The Member has the right to file a complaint regarding any dispute with AHP.
  • Qualified clinical personnel will make determination of all clinical complaints involving clinical decisions.
  • AHP will allow only qualified clinical personnel to make determinations with regard to the provision of your benefits. Any denial will be accompanied by an explanation and a basis behind the decision and further appeal rights.
  • AHP will not retaliate or take any discriminatory action against the member because they filed a complaint or appeal.
  • The member has the right to designate a representative to file complaints and appeals on his behalf.
  • The member has a right to file a complaint verbally when the dispute is about referrals or covered benefits.
The following timeframes apply to the Grievance\Appeal Procedure:

  1. The Member or designee has no less than 60 business days after receipt of the notice of the complaint determination to file a written appeal.
  2. Grievance appeals may be submitted in writing, on a form provided by AHP or verbally.
  3. Within 15 business days of receipt of the grievance\appeal, AHP shall provide written acknowledgment including the name; address and telephone number of the individual designated to respond to the appeal. AHP will indicate what additional information, if any must be provided for AHP to render a decision.
  4. Personnel qualified to review the complaint, including licensed, certified or registered health care professionals who did not make the initial determination will decide grievance appeals related to clinical matters.
  5. Qualified personnel at a higher level than the personnel who made the original complaint determination will make grievance appeal determinations of non-clinical matters.
  6. Appeals will be decided and notification provided to the Member no more than:
    • 2 business days after the receipt of all necessary information when a delay would significantly increase the risk to a Member's health.
    • 30 business days after the receipt of all necessary information in all other instances.
  7. The written notice of an appeal determination will include the detailed reasons for the determination, the clinical rationale if applicable, and instructions for any other appeal.

The notice will also inform the member of their right to contact the State Insurance or Health Department at any time during the complaint process.

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