Qualifying new members may continue an ongoing course of treatment with a current (non-network) provider for a transitional period.
This policy is applicable if member has a life threatening or degenerative and disabling condition, for a transitional period of up to (60) days from the effective date of enrollment. If the member has entered the second trimester of pregnancy at the effective date of enrollment, the transitional period shall include postpartum care directly related to the delivery.
Care will be authorized by Atlantis Health Plan if the provider signs an agreement accepting Atlantis Health Plan's established rates as payment in full; adheres to Atlantis Health Plan's quality improvement requirements; provides medical information related to care; adheres to Atlantis Health Plan's policies and procedures. Precertification by Atlantis Health Plan's Utilization Department is required.
IDENTIFICATION OF Atlantis Health Plan MEMBERS
Atlantis Health Plan reimburses physicians only for services rendered to eligible members. Physicians (or their office staff) are responsible for verifying each member's eligibility prior to treatment. All members have an identification card, which must be presented each time services are requested. A copy of the Atlantis Health Plan identification card is illustrated on page 10 of this manual. Please examine all data on the card carefully to determine the member's eligibility and extent of coverage. The complete member number must be used when submitting claims to Atlantis Health Plan.
Due to the nature of the Atlantis Health Plan delivery system, whereby members access the system principally through their Primary Care Physician, the procedures to be followed by Primary Care Physicians and Specialists in verifying member eligibility will be somewhat different. Therefore, identification procedures to be followed in Primary Care Physician and Specialists offices are outlined separately below.
Primary Care Physician
When a member arrives in the office, the physician's office staff must determine if the member is eligible for services and if the member is in fact an active member of Atlantis Health Plan. Enrollment can be verified by contacting Atlantis Health Plan. The member must display his or her Atlantis Health Plan Identification Card. If the member presents himself or herself as enrolled and has disenrolled, then the member is responsible for the charges associated with the care provided.
When a member arrives in the office, the physician's office staff must determine member eligibility by requesting the member to display his or her Atlantis Health Plan identification card.
All referrals to specialists must be coordinated through the member's Primary Care Physician. Therefore, in addition to verifying member eligibility, it is incumbent upon the specialist to determine if in fact the member's Primary Care Physician has referred the member. It is the member's responsibility to obtain the proper referral from the Primary Care Physician. It is the Primary Care Physician's responsibility to ensure you have the appropriate referral at the time of the member's initial visit. Please see the Pre-authorization Section of this manual for a full explanation of the Referral Form guidelines. If the member presents as enrolled with Atlantis Health Plan and has disenrolled, the member is responsible for the charges associated with the care provided.
For emergency admissions, the Hospital must confirm member status and secure a pre-certification number from Atlantis Health Plan's Utilization Department.