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For all members, in-network services entail the lowest out-of-pocket expenses. For patients with Health Plan contracts, the decision to refer a member to an in-network specialist is at the discretion of the Primary Care Physician based on medical necessity. Health Plan members may not self-refer. The only exception to this policy is in regard to referrals for OB/GYN services. Routine gynecological services (including Pap smears, an annual check?up, and mammography screening when appropriate) are available to all female members of the Plan. They may receive these services from their Primary Care Provider or they can go to an Atlantis Health Plan participating gynecologist or obstetrician/gynecologist of their choice. (The list of participating OB/GYN's is included in the Atlantis Health Plan Provider Directory.) If a Member chooses to go to an OB/GYN for primary and preventive gynecological care, they are entitled to two (2) visits per year without a referral.

If in the opinion of the PCP a member's condition requires a referral to a specialist not in the Atlantis Health Plan's provider network, the PCP must contact Atlantis Health Plan Utilization Department to pre-certify the request. The request needs to be authorized by the Atlantis Medical Director. Once approved, the PCP, the out-of-plan physician, and the member will be notified in writing of the disposition. The notification outlines the scope of the referral. Additional treatment must be pre-authorized. Under no circumstances should a member with an Health Plan contract proceed with an out-of-plan referral without prior approval. In an emergency, a phone approval may be sought through the Atlantis Health Plan Health Services department and the paperwork will follow according to our routine pre-authorization policy and procedure. The services should add no additional cost beyond what enrollees pay for Atlantis Health Plan's In-network services.

Referral Form Guidelines:

Primary Care Responsibilities:

  • Fill out the form completely. Keep the pink copy for your records. Give the white and green copies to the patient, who will take them to the Specialist.
  • Do not send a copy of the referral to Atlantis Health Plan, as this is the responsibility of the Specialist. If the member requires emergency care, notify the participating specialist by phone and mail or fax the referral to the specialist's office.
  • The first visit to the specialist must occur within ninety days of the date the referral was issued. The referral is valid for no more than six visits (the PCP may restrict/reduce the number of referred visits) and no longer than one year from the date of issuance. Unless restrictions are listed on the referral form, all covered treatments and hospitalization do not require the primary care physician's prior approval.
  • A different diagnosis requires a new referral form.
Specialist Responsibilities:
  • Attach the green copy of the Referral Form to your initial claim reimbursement form.
  • Subsequent visits (which will be noted at Atlantis Health Plan after initial receipt) will be monitored by Atlantis Health Plan for payment. It is the specialist's responsibility to advise and request from the PCP another referral form should the treatment exceed the limits of authorization.
If you have not received a copy of the referral form and/or a telephone authorization from the Primary Care Physician when the member arrives for the appointment, you may inform the member that he/she is financially responsible for the visit. It is highly recommended that a member sign a waiver in such instances

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