Appeals and Grievances

4 important points to consider regarding your appeals or grievances process

  1. When can you file an appeal or grievance?

  • When you experience dissatisfaction with the quality of your health care, waiting times or receive poor service by our providers or pharmacy network.
  • If you wish to complain about the design of your plan benefits, the established co-payments and the service received at a pharmacy.
Reclamo
  1. What is the deadline to file a complaint?

  • The complaint must be filed within
    60 days of the event or incident.
Calendario
  1. How to file a complaint?

  • Your written request must include: name, postal address, affiliate number, reasons for the complaint and any other evidence you wish to include with a brief description of the matter.
  • Also, you must include the names of the people involved, the date of the incident, copy of documents and other information that can help in our investigation.
Solicitud
  1. Need more information?

For detailed information about appeals and grievances, you can call our Member Service Center or refer to Chapter 9, Section 5, 6 and 7 of your Evidence of Coverage.

For Optimo and Basic covers, refer to Chapter 7, Section 4, 5 and 9 of your Evidence of Coverage.

Información

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 (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

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 (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.

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

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

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 (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.







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 (787) 993-3261

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

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

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.

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 (787) 993-3261

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

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.

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

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

FORM TO APPOINT A REPRESENTATIVE

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 (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.