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An Atlantis Health Plan clinical reviewer will deny coverage of requested health services when the type of service or the level of care requested fail to meet the established written utilization review criteria of the plan for medical necessity and appropriateness. A clinical peer reviewer is a physician who possesses a current and valid non-restricted license to practice medicine, or a health care professional other than a licensed physician who, where applicable, possesses a current and valid non-restricted license, certification or registration or, where no provision for a license or certificate, is credentialed by the national accrediting body appropriate to the profession and is in the same profession/specialty as the health care provider who typically manages the medical condition.

Notices of adverse determination are made in writing and include:

1. The reasons for the determination
2. Instructions for filing an appeal
3. The opportunity to obtain a copy of the clinical criteria on which the decision was based, upon request of the member or of the member's designee.
4. Specification of any additional information, which should be provided to, or obtained by the plan in order to render a decision on the appeal.

A member, the member's designee, or the member's health care provider may request from Atlantis Health Plan an appeal of the adverse determination. Various types of appeals and time frames for responses are provided for, depending on the circumstances under which the adverse determination was made

• Expedited appeal with access to a clinical peer reviewer within one (1) business day, and a determination completed in two (2) business days of receipt of necessary information to conduct the appeal.
• Standard appeal with a determination completed within sixty (60)days of receipt of necessary information to conduct the appeal. Atlantis Health Plan will issue written notification of the appeal determination within two (2) business days.
• Retrospective review determination is made within thirty (30) days of receipt of necessary information with which to render the decision.

INTERNAL APPEAL PROCEDURE

If the adverse determination is upheld after reconsideration, Atlantis Health Plan will issue a written notice of adverse determination. The member or the member's designee or the member's health care provider may then proceed to further appeal the decision using either the expedited appeal or the standard appeal, as defined below.

1. Except in cases of adverse determinations made during retrospective review, an Expedited Appeal is allowed in situations involving continued or extended health care services, procedures or treatments or additional services for a member undergoing a course of continued treatment prescribed by a health care provider; when the health care provider believes an immediate appeal is warranted.

   Within one (1) business day of receiving notice of an expedited appeal, Atlantis Health Plan will give the member's health care provider reasonable access to a clinical peer reviewer other than the clinical peer reviewer who rendered the adverse determination.

   The clinical peer reviewer will render a determination within two (2) business days of receipt of necessary information to conduct the appeal.

   Expedited appeals, which do not result in a resolution satisfactory to the appealing party may be further appealed through the standard appeal process, as defined below, or a request can be made for an external appeal (refer to External Appeal Procedure - page 27).

2. Except in cases of adverse determinations made during retrospective review, a Standard Appeal process is required in all situations other than those described above.

   These appeals may be filed in writing or by telephone. To file a standard appeal of an adverse determination, an appealing party has no more than forty-five (45) days after the member receives a notice of adverse determination and Atlantis Health Plan receives all necessary information to conduct the appeal.

   Atlantis Health Plan will send written acknowledgment of receipt of the appeal to the appealing party within fifteen (15) days of the date of the receipt. Atlantis Health Plan will assign a clinical peer reviewer other than the one who rendered the adverse determination, and the appeal determination will be rendered within sixty (60) days of receipt of information necessary to conduct the appeal.

   Thereafter, Atlantis Health Plan will issue written notification of the appeal determination within two (2) business days to the member, the member's designee and the member's health care provider. This notice will include reasons for the determination, with the clinical rationale provided where the adverse determination is upheld on the appeal.

3. Retrospective review determinations involve services, which have already been delivered to the member. An appeal or reconsideration of adverse determinations of this type will comply with the procedures of the standard appeal except that the appeal determination must be made within thirty (30) days of receipt of information necessary to conduct the appeal. Atlantis Health Plan will assign a clinical peer reviewer other than the one who rendered the adverse determination. As the member's health care provider, you may request an external appeal if the services in question were denied based on medical necessity and/or were considered experimental and/or investigational.

A member may file an application for an external appeal by a state-approved external appeal agent if they have received a denial of coverage based on medical necessity or because the service is experimental and/or investigational.

To be eligible for an external appeal, the member must have received a final adverse determination as a result of Atlantis Health Plan's first-level appeal process, or both the member and Atlantis Health Plan must jointly agree to waive the UR appeal process.

Members may obtain an external appeal application from:

• The New York State Department of Insurance at 1-800-400-8882, or its website (www.ins.state.ny.us),
• Our Member Services Department at 1-877-MD-ASSIST.

The application for external appeal must be made within 45 days of the member's receipt of the notice of final adverse determination as a result of Atlantis Health Plan's first-level appeal process, or within 45 days of when the member and Atlantis Health Plan jointly agree to waive the internal appeal process.

However, regardless of whether a member participates in additional Atlantis Health Plan internal appeals, an application for external appeal must be filed with the New York State Department of Insurance within 45 days of the member's receipt of the notice of final adverse determination from Atlantis Health Plan's first-level appeal to be eligible to be reviewed by an external appeal agent.

Members will lose their right to an external appeal if they do not file an application for an external appeal within 45 days from their receipt of the final adverse determination from the first level internal plan appeal.

The application will include instruction for mailing to the New York State Department of Insurance. The members (and their doctors) must release all pertinent medical information concerning their medical condition and request for services. An independent external appeal agent approved by the state will review their request to determine if the denied service is medically necessary and should be covered by Atlantis Health Plan. All external appeals are conducted by clinical peer reviewers. The agent's decision is final and binding on both the member and Atlantis Health Plan.

An external appeal agent must decide a standard appeal within 30 days of receiving the member's application for external appeal from the state. Five (5) additional business days may be added if the agent needs additional information. If the agent determines that the information submitted to it is materially different from that considered by Atlantis Health Plan, Atlantis Health Plan will have three (3) additional business days to reconsider or affirm its decision. The member and Atlantis Health Plan will be notified within 2 business days of the agent's decision.

The member may request an expedited appeal if their doctor can attest that a delay in providing the recommended treatment would pose an imminent or serious threat to their health. The external appeal agent will make a decision within three days for expedited appeals. Every reasonable effort will be made to notify the member and Atlantis Health Plan of the decision by telephone or fax immediately. This will be followed immediately by a written notice.

In the event an adverse determination is overturned on external appeal, or in the event that Atlantis Health Plan reverses a denial, which has been the subject of external appeal, Atlantis Health Plan shall provide or arrange to provide the health care service(s) requested.

If the member is no longer insured by Atlantis Health Plan at the time of an external appeal agent's reversal of Atlantis Health Plan's utilization review denial, Atlantis Health Plan will not be required to provide any health care services.

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