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Acute Condition - Onset of illness having rapid or sudden onset with severe symptoms.

Co-payment - An amount for which the member is responsible for payment, due at the time the health care is rendered.

Emergency Medical Condition - 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 (1) placing the health of the person afflicted with such condition in serious jeopardy; or (2) serious impairment to such person's bodily functions; or (3) serious dysfunction of any bodily organ or part of such person; or (4) serious disfigurement of such person.

Extended Care Facility - A nursing home or nursing center that is licensed to operate in accordance with all applicable state and local laws to provide twenty-four hour nursing care. Such a facility may offer skilled, intermediate or custodial care, or any combination of these three levels of care.

External Appeal - A member or a member's health care provider has the right to request an external appeal of any adverse determination made by Atlantis Health Plan's Appeals Department that was based on the grounds that the requested service was not medically necessary or is experimental and\or investigational in nature. External appeals are performed by a state approved external appeals agent.

Home Health Agency - An agency licensed under all applicable state and local laws to provide skilled nursing and rehabilitation services in the home setting.

Hospital - An institution which is licensed under all applicable state and local laws and regulations to provide, under the supervision of physicians and surgeons, diagnostic and therapeutic services for the medical diagnosis, treatment and care of injured, disabled or sick persons in need of acute inpatient hospital care, and which is registered as a general hospital by the American Hospital Association and is accredited by the Joint Commission on Accreditation of Healthcare Organization.

Inpatient - A patient receiving medical treatment from a physician that requires a hospital stay for twenty-four hours or more. All inpatient admissions are reviewed for medical necessity.

Medically Necessary - A service, treatment, procedure, equipment, drug, device, or medical supply provided by a hospital, physician, or other provider of health care that is determined by Atlantis Health Plan to be:

  1. consistent with the symptom(s) or diagnosis and treatment of the member's bodily injury or sickness;
  2. appropriate under the standards of acceptable medical practice to treat that bodily injury or sickness;
  3. not solely for the convenience of the member, physician, hospital, or other provider of health care;
  4. the most appropriate service, treatment, procedure, equipment, drug, device, or supply which can be safely provided to the member, and
  5. the most economical manner of accomplishing the desired result.
Member - Any person who is enrolled in and is eligible to receive health care services from a plan offered or administered by Atlantis Health Plan. The insured.

Panel - The net total of Atlantis Health Plan members who have selected a particular physician as their primary care physician.

Peer Review - The continuous evaluation of services to determine whether necessary levels of service are being provided in a timely and efficient manner. The quality and appropriateness of services as well as the setting of such services are included in the evaluation process.

Outpatient - A patient receiving medical treatments under the direction of a physician, but not require a hospital stay greater than twenty-three hours.

Participating Physician - A provider of health services who contracts with or has an agreement with Atlantis Health Plan.

Primary Care Physician - A Family Practitioner, General Practitioner, Internist, or Pediatrician who has agreed to be responsible for the coordination of care for the member on an ongoing basis and to maintain unified medical records for each member.

Service Area - The designated area within which Atlantis Health Plan is licensed to conduct business and within which covered health care services are available and accessible to members. The current service area includes the five boroughs of New York City (Bronx, Kings, Manhattan, Queens and Richmond).

Specialist Physician - A physician who is Board-certified in an approved specialty training program or is generally recognized by the physician community as being skilled in the stated specialty.

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