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Referral/Authorization Summary Sheet


Procedures/Services NOT requiring pre-authorization or written referral:

  1. PCP Office Visit
  2. OB/GYN Office Visit
  3. Routine Vision Care
  4. Mammography
  5. Prescription /Pharmaceutical Services (exception list attached)
  6. Routine Radiology Services (plain films)
  7. Laboratory services
Procedures/Services requiring written referrals:
  1. A written referral is issued for consultation, diagnosis, or treatment
  2. Referrals are valid for ninety (90) days from the date of the requesting provider's signature
  3. Fill in the complete name and identification number for the member; include the member's medication and allergy history
  4. Include a rule out or working diagnosis
  5. Fill in the Specialist's name*
  6. PCP must sign and date the referral
  7. Send white & pink copies and any relevant attachments to the specialist
  8. PCP is to retain the green copy for his/her records
*Refer to the Atlantis Health Plan Provider Directory for a listing of participating network specialists. Please call the Atlantis Health Plan Utilization Department at 1-800-270-9072 if there are no providers listed for a particular specialty. Health Plan policyholders require pre-authorization for out-of-network referrals. For all members, in-network referrals entail the lowest out-of-pocket expense

Services requiring Plan notification (1-800-270-9072):

  1. Urgent inpatient admissions
  2. Emergency inpatient admissions
  3. Emergency Room services within forty-eight (48) hours of treatment

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