Appeals and Grievances

Process to File a Grievance

The complaint or grievance process is only used for certain types of problems. This includes problems related to health care quality, waiting times, and the customer service you receive. It can also be used to express general dissatisfaction about the design of the plan benefits, established copayments, and the service received at a pharmacy. The grievance must be submitted within 60 days after the event or incident.

For example, complaints about our network providers or pharmacies, including complaints about the quality of your health care. This type of complaint does not involve Organization Determinations, Part D Coverage determinations, or payment disputes.

Your written request should include: your name, mailing address, member number, reasons for the complaint, and any evidence you wish to attach, with a brief description of the problem causing your complaint. You should also include the names of the people involved, incident date, document copies, and any other relevant information that may help in our investigation.

For detailed information about appeals and grievances, you may contact our Customer Service Center, or refer to Chapter 9, Sections 5, 6, and 7 of your Evidence of Coverage. For Óptimo and Basic plans, refer to Chapter 7, Sections 4, 5, and 9 of your Evidence of Coverage.

How to file a grievance with your plan

  • Send an email to appeals-grievances@sssadvantage.com
  • Call 1-888-620-1919, Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520
  • Send a fax to 787-993-3261
  • Mail a letter to:
Triple-S Advantage, Inc.

Appeals and Grievances Department

PO Box 11320
San Juan, PR 00922

How to file a complaint with Medicare

You may submit feedback on your health plan or Medicare drug plan. Your comments will help the Centers for Medicare and Medicaid continue improving the quality of the Medicare program.

FILE A COMPLAINT WITH MEDICARE

Process to File an appeal

The initial determination we make is the starting point to deal with your requests to cover a Part C medical care or service you need, or to pay for a Part C medical care or service you already received. Initial decisions about Part C medical care or services are called “organization determinations”. With this decision, we explain whether we will provide the Part C medical care or service you are requesting, or pay for the Part C medical care or service you already received.

If you are not satisfied with our coverage decision, you may file an appeal. An appeal is the formal way of requesting a review to change our initial determination for coverage or payment.

We will review the initial coverage or payment decision, and verify if the rule used to process the decision was adequate.

Your appeal will be reviewed by a reviewer different from the first one. We will complete the review and inform you about our determination.

For detailed information about appeals and grievances, you may contact our Customer Service Center, or refer to Chapter 9, Sections 5, 6, and 7 of your Evidence of Coverage. For Óptimo and Basic plans, refer to Chapter 7, Sections 4, 5, and 9 of your Evidence of Coverage.

How to file an appeal

You may submit the information using any of the following methods:

  • Send an email to appeals-grievances@sssadvantage.com
  • Call 1-888-620-1919 to file a verbal appeal, Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.
  • Send a fax to 787-993-3261
  • Mail a letter to:
Triple-S Advantage, Inc.

Appeals and Grievances Department

PO Box 11320
San Juan, PR 00922

Appointing a Representative

If you would like to appoint a representative to file a grievance, to request a coverage determination or exception or request an appeal on your behalf. You and the person being appointed must fill out this form (or a written equivalent) and submit your request.

  • You may call 1-888-620-1919, Monday through Sunday, from 8:00 a.m. to 8:00 p.m. to orally file an appeal. TTY/TDD users should call 1-866-620-2520.
  • Mail a letter to:
  • Triple-S Advantage, Inc.

    Appeals and Grievances Department

    PO Box 11320
    San Juan, PR 00922
    Form to Appoint a Representative

Appeal Process for Part D Drugs

How to file an appeal for Part D drugs

If you disagree with our decision to deny coverage or payment for drugs, you may file an appeal and stop the services you are receiving.

For example, you may file an appeal if we don’t pay for a drug or service you understand you should receive. You have 60 days to file an appeal for Part D drugs.

  • If you are appealing a decision we have made about a Part D drug, you or your doctor should decide if you need a fast appeal. You, your doctor, or your representative may request a fast appeal.
  • For a fast decision on a Part D drug – we have 72 hours to decide, but we will decide sooner if your health condition requires it. If we do not decide within 72 hours, your request will automatically go to appeal Level 2.
  • For a standard decision on a Part D drug – we have 7 days to decide, but we will decide sooner if your health condition requires it. If we do not give you a decision within 7 days, your request will automatically go to appeal Level 2.

For detailed information about Part D drug appeals, you may call our Customer Service Center, or refer to Chapter 9, Section 6.5 of your Evidence of Coverage.

REQUEST FORM TO FILE APPEAL FOR PART D DRUGS
  • Send an email to appeals-grievances@sssadvantage.com
  • Call 1-888-620-1919, Monday through Sunday, from 8:00 a.m. to 8:00 p.m.
    TTY/TDD users should call 1-866-620-2520.
  • Send a fax to 787-993-3261
  • Mail a letter to:
Triple-S Advantage, Inc.

Appeals and Grievances Department

PO Box 11320
San Juan, PR 00922

How to obtain an aggregate number of grievances, appeals, and exceptions filed with Triple-S Advantage

As a member of our plan, you have the right to get information from us. This includes information about the number of grievances and appeals made by members, and the plan’s performance ratings, including how it has been rated by the plan members, and how it compares with other Medicare Advantage health plans.

If you want this information, you may contact the Customer Service Department, Monday through Sunday, from 8:00 a.m. to 8:00 p.m. at 1-888-620-1919. TTY/TDD users should call 1-866-620-2520 and request the information related to grievances, appeals and exceptions filed with the plan.

Last update: 10/04/2017

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