Member Services

  


How do I file a complaint with Medicare?

1. Click on the following link to submit feedback about your Medicare health plan or prescription drug plan. This will help the Centers for Medicare & Medicaid Services to continue improving the quality of the Medicare program.

FILE A COMPLAINT WITH MEDICARE

How do I request a reimbursement for medical services?

1. Print and fill out the Medical Services Reimbursement Form
2. Send it along with the corresponding payment receipt to the address or fax number below

Triple-S Advantage, Inc.
Claims Department
PO Box 11320
San Juan, Puerto Rico 00922
Fax: (787) 993-3261

REIMBURSEMENT FORM

How do I appoint a representative?

1. Request a coverage determination or an appeal on behalf of a member.
2. Both of you must fill out the following form.

FORM TO APPOINT A REPRESENTATIVE

Rules for Out-of-Network Services

Health Maintenance Organization (HMO) and Platino Plans

With limited exceptions, while you are a member of our plan, you must use network providers to get your medical care and services.

The only exceptions
are emergencies


urgently needed care, and dialysis services when providers in the network are temporarily unavailable or inaccessible, for example if you are outside the service area.

You can obtain care
from out-of-network providers

when the providers of specialized services are not available in our network.

Prior authorization
is needed.


You or your doctor must obtain
the prior authorization.


Contact Customer Service for more information on how to request prior authorization for out-of-network services.


For detailed information, refer to
your Evidence of Coverage or contact the plan.

Preferred Provider
Organization (PPO)
Plans

You can choose
to receive care

from out-of-network
providers.

Our plan will cover services from either in-network or out-of-network
providers, as long as the services are covered benefits and are medically necessary.

You can obtain care
from out-of-network providers

when the providers of specialized services are not available in our network.

Prior authorization
is needed.


You or your doctor must obtain
the prior authorization.


Contact Customer Service for more information on how to request prior authorization for out-of-network services.


For detailed information, refer to
your Evidence of Coverage or contact the plan.

Preferred Provider
Organization (PPO)
Plans

You can choose
to receive care

from out-of-network
providers.

Our plan will cover services from either in-network or out-of-network
providers, as long as the services are covered benefits and are medically necessary.

However,
if you use an out-of-network provider,
your share of the costs for your covered services may be higher.

i

You can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare, except for emergency care.

ii

For services other than emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

iii


You don’t need to get a referral or prior authorization when you get care from out-of-network providers.

iv

If you are using an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, you will not have to pay a higher cost-sharing amount for the service.

Out-of-Network
Pharmacy Coverage

To find a qualifying pharmacy, you can check our Provider Directory or contact our Customer Services Department, toll free.

To fill your
drug prescriptions,
you must visit one of our contracted pharmacies.

You may go to any network pharmacy of your preference.

Out-of-Network
Pharmacy Coverage

To find a qualifying pharmacy, you can check our Provider Directory or contact our Customer Services Department, toll free.

To fill your
drug prescriptions,
you must visit one of our contracted pharmacies.

You may go to any network pharmacy of your preference.

1-888-620-1919

Monday through Sunday, from 8:00 a.m. to 8:00 p.m.

1-866-620-2520

If you obtain your drug in an out-of-network pharmacy, you will have to pay the full cost of the prescription and send us a written request for reimbursement.

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1

Fill out the Reimbursement Form

2

Send it along with the corresponding payment receipt to the address or fax number below

3

Please include the original purchase receipts with your request

4

Your reimbursement request must include the following:

  • Name and contract number of the beneficiary who received the service
  • Date of service
  • Stamp or letterhead of pharmacy’s name and address
  • Prescription number
  • Drug name
  • Dispensed quantity
  • Amount paid
  • Daily dose
  • Reason for requesting reimbursement
  • For services that require a precertification, include a copy of the precertification.
  • National Drug Code (NDC)
  • National Provider Identifier (NPI) of the prescribing physician and pharmacy

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Triple-S Advantage, Inc.
is an independent licensee of the BlueCross BlueShield Association.

This allows us to engage with other
BlueCross BlueShield
Licensees (Host Blues) through the
Medicare Advantage Program.

When members access healthcare
services outside the
geographic area of service...

the claim for those services will be processed through the Medicare Advantage Program and paid in accordance with the current rules of the Medicare Advantage Program policies in effect.

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. We generally cover drugs filled at an out-of-network pharmacy, only when you are not able to use a network pharmacy.

Triple-S Advantage, Inc.
is an independent licensee of the BlueCross BlueShield Association.

This allows us to engage with other
BlueCross BlueShield
Licensees (Host Blues) through the
Medicare Advantage Program.

When members access healthcare
services outside the
geographic area of service...

the claim for those services will be processed through the Medicare Advantage Program and paid in accordance with the current rules of the Medicare Advantage Program policies in effect.

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. We generally cover drugs filled at an out-of-network pharmacy, only when you are not able to use a network pharmacy.



Get in touch with our experts:

Sales Representative

1-877-207-8777

TTY/TDD Users

Monday through Friday
from 8:00 a.m. to 8:00 p.m.

I am undecided. Please call me to provide some guidance.

By completing this form, you as a beneficiary or authorized representative agree to have one of our sales representatives contact you to discuss the products Triple-S Advantage offers under Part C. Please be aware that the person calling you is a Medicare employee or subcontractor. They do not work directly with the federal government. This person could receive compensation based on your plan enrollment.

This selection does NOT obligate you to enroll in a plan, it does not affect your current membership, and it will not enroll you in another Medicare plan.

Get to Know Medicare

Member Service

1-888-620-1919

TTY/TDD users

1-866-620-2520

Monday thru Sunday, from 8:00 am to 8:00 pm

Service for Providers

1-855-886-7474

Monday thru Friday, from 8:00 am to 5:00 pm

Teleconsulta

1-800-255-4375

Teleconsejo

1-877-879-5964

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