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Below is a sample of an Atlantis Health Plan Membership Card:

OUT-OF-NETWORK SPECIALIST CARE AND SPECIALTY CARE CENTERS

For all patients, in-network services entail the lowest out-of-pocket expenses. For patients with Health Plan contracts, with the exception of care for emergency conditions, services must be approved by the participating primary care provider and provided by a participating provider. Under the following circumstances, however, upon referral, and approval by Atlantis Health Plan, the patient may see a specialist or provider that is not in the Atlantis Health Plan network or receive ongoing specialty care from non-participating providers.

This care will be provided at no additional cost to the member beyond what would be paid for services within the network.

Out-of-network referrals will be considered under the following circumstances:

1. If Atlantis Health Plan does not have a health care provider with appropriate training and experience within the network to meet the patient's medical needs.

2. If the member has been given a positive or negative diagnosis of cancer or a recommendation of a course of treatment for cancer. Atlantis Health Plan will approve coverage for a second medical opinion from a non-participating specialist, including but not limited to a specialist affiliated with a specialty care center for the treatment of cancer.

3. If the patient has a life-threatening condition or disease or degenerative and disabling condition or disease with requires prolonged specialized medical care, Atlantis Health Plan may approve a referral to a specialist to provide and/or to coordinate the member's primary and specialist care. Atlantis Health Plan may limit the number of visits or the period of authorization and require the specialist to provide information to the member's in-plan primary care provider.

4. If the member has a life-threatening disease or degenerative and disabling condition or disease, which requires prolonged specialized medical care, Atlantis Health Plan may approve a referral to a designated or accredited specialty care center not in the Atlantis Health Plan network. Atlantis Health Plan does not cover travel expenses associated with referrals to specialty care centers even if significant travel is required unless travel is included in the rate of payment negotiated with the specialty care center.

   The Atlantis Health Plan Medical Director will consult with the requesting provider to decide if such a referral is appropriate. The member, the PCP, in in-network specialist, or the out-of-network provider may call the Atlantis Health Plan Utilization Department and request a standing referral to an out-of-network specialist and/or out-of-network specialty care center.

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