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:
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
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.
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 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.