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Clinical Review Criteria

Atlantis Health Plan utilizes nationally recognized criteria as well as internal practice guidelines and standards for determination of clinical appropriateness. These criteria whether utilized internally or through delegation to an authorized external review agent, are selected, developed, approved, applied, managed and overseen by the plan's Utilization Management/Quality Improvement Committee with the support of administration, the medical directors, and the utilization management department, to ensure clinical consistency and appropriateness of all criteria utilized by AHP. Clinical review criteria and practice guidelines are reviewed annually or as necessary by the UM/QI committee. Along with industry recognized criteria, decisions and determinations are also based upon the clinical reviewer's knowledge and judgment on a case by case basis.

AHP clinical reviewers utilize InterQual criteria sets to assist in the review of inpatient, outpatient procedures, and imaging requests to confirm the appropriateness and medical necessity of the services. Complete criteria sets are maintained at AHP's administrative offices, and are available for reference to authorized entities, prospective members, providers and subscribers upon request. To ensure the appropriate and prompt release of criteria, the request should be made to: Health Services Department, Atlantis Health Plan, 45 Broadway, Suite 300, New York,NY 10006.