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Procedures Requiring Pre-Authorization:

[Call Atlantis Health Plan Utilization Management 1-800-270-9072 for pre-auth requests. Seven days' notice is required prior to admission and/or services being rendered]

FOR ALL MEMBERS, IN-NETWORK SERVICES ENTAIL THE LOWEST OUT-OF-POCKET EXPENSES. Payment is subject to eligibility, policy limits, and exclusions.

  • Ambulance/Ambulette for all non-emergency transportation
  • Ambulatory/Outpatient surgery
  • Anesthesia for endoscopic procedures
  • Arteriography
  • Arthrography
  • Assistant Surgeon
  • Audiology treatment (Audiology diagnostic tests do not require pre-authorization)
  • Behavioral Health (all services)
  • Cardiac Catheterization
  • Cardiac and Pulmonary Rehabilitation
  • Cast Room
  • Chemotherapy
  • Chorionic Sampling
  • CT Scan (all)
  • D & C (including elective abortions)
  • Diagnostic sleep studies (to assess sleep apnea and other sleep disorders)
  • Dialysis (all types)
  • DME; all rentals and purchases of equipment costing >$500
  • Elective in-patient admissions
  • GI Services, including all endoscopy except sigmoidoscopy
  • Home Health Care
  • Hospice services
  • Injectable Drugs - See attached list
  • In-office Surgery
  • Investigational devices, treatments, or procedures
  • IV Therapy (performed outside the hospital)
  • Labor/Delivery Room
  • Lithotripsy
  • Home social services
  • Nuclear Medicine services
  • Observation beds
  • Occupational Therapy (if a covered benefit)
  • Orthotics/Prosthetics (if a covered benefit)
  • Out-of-network facility (pre-authorization mandatory for Health Plan policyholders)
  • Out-of-network specialist (pre-authorization mandatory for Health Plan policyholders)
  • Outpatient surgery (except minor skin surgery - contact Atlantis Health Plan UM for CPT codes)
  • PET Scan
  • Physical Therapy (if a covered benefit)
  • Psychiatric/Psychological services
  • Psychiatric/Psychological treatment
  • Radiation Therapy
  • Rehabilitation facility
  • Respiratory services
  • Skilled Nursing (if a covered benefit)
  • Sonograms, obstetrical (>two per pregnancy)
  • Speech Therapy (if a covered benefit)
  • Subacute Care facility
  • Therapeutic Radiology
  • Transplants
  • Treatment/Observation room
Authorization phone 1-800-270-9072

For all patients, preferred formulary drugs entail the lowest out-of-pocket expense. Payment is subject to eligibility, policy limits, and exclusions. Drugs may be added to or removed from the list as determined by the Atlantis Health Plan Board.

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