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COVERAGE ARRANGEMENTS
Participating physicians shall ensure, or make arrangements for, twenty-four hour, seven days a week coverage to all members.
Participating physicians agree that in the event of their absence, a coverage arrangement will be made with a physician who is, whenever possible, a participating physician within the Health Plan's network. Participating physicians also agree that, in the event of coverage by a non-participating physician it will be the responsibility of the participating physician to ensure that the non-participating physician will (1) accept the fee from the Health Plan as full payment for services delivered to member; (2) accept the Health Plan's peer review procedures; (3) look solely to the Health Plan for compensation for covered services provided to members and shall at no time bill or otherwise seek compensation for covered services from members, except for applicable co-payments. The Plan must be notified in advance, or as soon as is reasonably possible, of the use of a non-participating provider in a coverage arrangement.
PRE-AUTHORIZATION PROCESS
Atlantis Health Plan's Utilization Department is open Monday through Friday from 9 a.m. to 5 p.m. and can be reached toll free at 1-800-270-9072. If you are unable to contact us during these times, you may FAX your request anytime to Atlantis Health Plan at 212-747-8375. An Atlantis Health Plan representative will contact you on the next business day.
Decisions regarding prior authorization will be completed three (3) business days or less after Atlantis receives the necessary information with which to render a decision. The member and his/her provider will be notified by telephone and in writing of the determination. This letter will include instructions for an appeal and advise that the clinical rationale for the denial will be provided upon request.
Failure by Atlantis Health Plan to make a determination within the required time periods set forth in Article 49 of the Public Health Law shall be deemed to be an adverse determination subject to internal appeal.