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Atlantis Health Plan has attempted to provide its' members with comprehensive benefit packages which provide the basic primary, preventive and specialty care necessary for good health. Covered Services include:

Ambulance Allergy Testing and Treatment Blood and Blood Products Adult Periodic Physical Exams Emergency Room Care Chiropractic Care Hemodialysis Diabetic Equipment and Education Home Health Care Diagnostic X-ray Laboratory Hospice Care DME Prosthetics Medical Supplies Inpatient Care Maternity Care Mental Health Substance Abuse OB/GYN Services Mammography Pap Smears Organ Transplants Second Opinions Pre-Admission Testing Well-Child Care Radiation and Chemotherapy Rehabilitative Services Skilled Nursing Facility Surgical Services

However some medical procedures, services and medical supplies are either specifically excluded from contractual Covered Services or are subject to pre-existing condition exclusion for a specific time period. Further, some Employer Groups may have purchased additional benefit riders to enhance the core benefits package.

Covered services must be medically necessary and appropriate. As such, the Atlantis Health Plan Medical Director may, in the course of the pre-authorization process, either decline to approve a proposed medical procedure or approve an alternative treatment.

Atlantis Health Plan's Member Services Department may be contacted Monday through Friday from 9:00am to 5:00 pm to verify or clarify Covered Services. This verification should be done prior to rendering the service. In contracting with Atlantis, you agreed to accept Atlantis' reimbursement, as stated in the Participating Physician Agreement, as payment in full, less any Subscriber/patient co-payment. Therefore, Atlantis Health Plan members may not be billed any additional amounts for Covered Services.

A member may elect to receive medical care for contractually excluded services or for services determined by Atlantis to be not Medically Necessary. In such instances, you are required to advise the Member prior to providing the service, that the service is not covered, that Atlantis would not assume responsibility for payment, and clearly state the cost the Member must assume. It is highly recommended that a Member sign a waiver accepting liability in such instances.

Covered Services, which require Pre-authorization, may be found in the Pre-authorization and Referral Policies section. The following services are excluded from coverage. If these services are provided, the Member is responsible for payment.

• Experimental and investigational drugs or treatments
• Cosmetic Surgery
• Some types of Obesity Surgery, Weight Reduction Programs and all treatment for non-morbid obesity
• Artificial means of achieving pregnancy
• Routine foot care
• Dental Services
• Eyeglasses, contact lenses and examinations for the prescription or fitting thereof, unless covered by a benefit Rider.
• Radial Keratotomy and related procedures; Vision training.
• Hearing aids and any examinations for the purpose of prescription or fitting them.
• Outpatient prescription drugs, unless specifically covered or benefit has been added by a Rider.
• Drugs used in connection with weight reduction, smoking cessation or treatment of baldness.
• Prescription drugs dispensed in a physician/provider's office
• Autologous blood services
• Learning, Behavioral, and Developmental Disorders to include non-medical treatment for Mental Retardation
• Wigs or any other appliance or procedure related to hair loss
• Recreational, Educational or Sleep Therapy and related diagnostic testing
• Reports, Tests and Procedures not directly related to treatment of the Member, e.g., travel immunizations and employment/camp physicals
• Transsexual Surgery or related services where there is no organic basis
• Free Care; Care Provided by Family Members
• Rest Cures, Custodial Care and transportation
• Benefit provided under any State or federal Workers Compensation, employers' liability or occupational disease law.
• Benefits to the extent provided for any loss or portion thereof for which mandatory No-Fault benefits are covered.
• Treatment provided in government hospitals; benefits provided under Medicare benefits or other government program (except Medicaid).

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