Appeals and Grievances

An appeal is the formal process to which you are entitled as a member if we have made a coverage decision and you are not satisfied with it. Through this process, you can request a review of the determination.

The plan's initial determination is the starting point for working with requests you may have regarding coverage for a medical service or care under your Medicare Advantage plan (Part C) that you need or payment for a medical service or care under Part C that you have already received. Initial decisions regarding medical care or services under Part C are called 'organization determinations'. With this decision, we explain whether we will provide the medical care or service under Part C that you requested or whether we will pay for medical care or services under Part C that you have already received.

If we make a coverage decision and you are not satisfied, you can appeal the decision. An appeal is the formal way to request that we review and change our initial coverage or payment determination. You have up to 60 calendar days to file an appeal for Part C.

We will review the initial coverage or payment decision and verify the regulation used in processing the decision and whether it was adequate.

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

For detailed information on appeals and grievances, you can call our Member Service Center or refer to your Evidence of Coverage.

You can call our Member Service Center for help with questions about your benefits or any service you have received or are about to receive, pre-authorization status, requests for durable medical equipment, justifications for your medications or treatments, and more. You can also file your appeal during this call.

Email us at:
1760969998 1760969998 mo1760969998c.ega1760969998tnavd1760969998asss@1760969998secna1760969998veirg1760969998-slae1760969998ppa 1760969998 1760969998 1760969998 1760969998

Call 1-888-620-1919,
Monday to Sunday, 8:00 a.m. to 8:00 p.m. Hearing-impaired individuals with specialized TTY/TDD equipment should call 1-866-620-2520

Fax us at (787) 993-3261

Mail us a letter to:
Triple-S Advantage, Inc. Appeals and Grievances Department. PO Box 11320. San Juan, PR 00922

If a member wishes to appoint a representative to file a grievance, request a coverage determination or exception, or request an appeal on their behalf, the member and the person accepting the representation must complete the form below (or equivalent in writing) and submit their request.

Call us at 1-888-620-1919, Monday to Sunday, 8:00 a.m. to 8:00 p.m. Hearing-impaired individuals with specialized TTY equipment should call 1-866-620-2520

Or mail us a letter with your request to:
Triple-S Advantage, Inc. Appeals and Grievances Department. PO Box 11320. San Juan, PR 00922

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 65 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.

Send an email to:
moc.e1760969998gatna1760969998vdass1760969998s@sec1760969998navei1760969998rg-sl1760969998aeppa1760969998

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 (787) 993-3261

Mail a letter to:
Triple-S Advantage, Inc. Appeals and Grievances Department. PO Box 11320. San Juan, PR 00922

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.

You can call our Member Service Center for help with questions about your benefits or any service you have received or are about to receive, pre-authorization status, requests for durable medical equipment, justifications for your medications or treatments, and more.

Call 1-888-620-1919, Monday to Sunday, 8:00 a.m. to 8:00 p.m. Hearing-impaired individuals with specialized TTY/TDD equipment should call 1-866-620-2520

Call 1-888-620-1919, Monday to Sunday, 8:00 a.m. to 8:00 p.m. Hearing-impaired individuals with specialized TTY/TDD equipment should call 1-866-620-2520

Email us at:
moc.e1760969998gatna1760969998vdass1760969998s@sec1760969998navei1760969998rg-sl1760969998aeppa1760969998

Fax us at (787) 993-3261

Mail us a letter to: Triple-S Advantage, Inc. Appeals and Grievances Department. PO Box 11320. San Juan, PR 00922

To file a grievance, including marketing complaints, you can call our Member Service Center at 1-888-620-1919 toll-free, Monday to Sunday, 8 a.m. to 8 p.m. Hearing-impaired individuals with specialized TTY equipment should call 1-866-620-2520
You can also call 1-800-Medicare.