Member Services

How to file a
complaint with Medicare?

Click on the link and submit your comments about your health plan or Medicare drug plan to help the Centers for Medicare and Madicaid Services continue to improve the quality of the program.

Submit a Complaint
with Medicare

How to request a reimbursement for medical services?

1. Print and complete the Medical Services Reimbursement Request

2. Send it together with the receipt of the service to the address or fax number indicated below, or send it via email to: moc.r1768437554psss@1768437554egatn1768437554avdao1768437554slobm1768437554eer1768437554

Triple-S Advantage, Inc.
Departamento de Reclamaciones
PO Box 11320
San Juan, Puerto Rico 00922-1320
Fax: 787-706-4015

REIMBURSEMENT
FORM

How do I appoint a representative?

1. Request a coverage determination or appeal on behalf of a member

2. Both must submit this application by completing the following form

Form to Appoint
a Representative

Rules for services outside the coverage area

Coordinated Care Plans (HMO) and Platino

Planes de Cuidado

Use our extensive network with over 13,000 health providers

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

Exceptions in case of emergency

Necessary emergency care, urgency and dialysis services when network providers are temporarily unavailable or inaccessible, for example, if you are outside the service area in the United States and its territories.

Out of Network Care

In some of our plans you can get care from out-of-network providers when specialized service providers are not available in our network.

You or your doctor must request prior authorization.

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

For detailed information consult your Evidence of Coverage or contact the plan.

Preferred Provider Plans (PPO)

  • You can choose to receive your care from out-of-network providers.
  • Our plan will cover services from in-network and out-of-network providers, as long as the services are covered benefits and they are medically necessary.
  • However, if you use an out-of-network provider, your share of costs for covered services may be greater.

Points to consider

  • 1 You can get care from an out-of-network provider, however, in most cases, that provider must be eligible to participate in Medicare, except in case of emergency care.
  • 2 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 total cost of the services you receive.
  • 3 You do not need to obtain a referral or prior authorization when you receive medical care from an out-of-network provider.
  • 4 If you use an out-of-network provider to receive emergency care, urgently needed services or out-of-area dialysis services, you may not have to pay a higher cost-sharing amount.

Out-of-network pharmacy coverage

To submit a written request for reimbursement (hard copy):

  • 1 To obtain prescription medications,
    visit the pharmacy of your choice
    within our contracted
    pharmacies.
  • 2 Check in our Provider Directory or contact our Member Service Center free of charge to find out which pharmacies are in our network.
  • 3
    Call Us! 1-888-620-1919
    Assistance for deaf members and TTY/TDD equipment
    1-866-620-2520
    Monday through Friday, from
    8:00 a.m. to 8:00 p.m.
  • 4 Generally, if you have to use an out-of-network pharmacy, you must pay the full cost (and not the normal part that corresponds to you) when you fill your prescription. You can ask us to pay you back for our share of the cost of the drug.

Drug reimbursement request

To submit a paper refund request:

  • 1 Complete the Drug Reimbursement request
  • 2 Send it together with the pharmacy purchase receipt to the address or fax number indicated below
  • 3 Include your purchase receipts with the request
  • 4 Your refund request must include the following:
    • Name and contract number of the insured person who received the service
    • Date of service
    • Stamp or letterhead with the name and address of the pharmacy
    • Recipe number
    • Name of the medication
    • Amount dispatched
    • Amount paid
    • Daily dose
    • Reason to request reimbursement
    • Copy of the pre-certification, for the services that require precertification
    • National Drug Code (NDC)
    • National Provider Identifier (NPI) of the pharmacy and the prescribing physician
Abarca Health, LLC.

Coverage Determination Department

1606 Ave. Ponce de León
San Juan, PR 00909-4830
Fax: 1-855-710-6727
Medication reimbursement request form

Services outside the coverage area through the Blue Card® Program

Out-of-Area Services

Triple-S Advantage, Inc. is an independent licensee of the BlueCross BlueShield Association. This allows us to interact with other BlueCross BlueShield (Host Blues) dealers through the Medicare Advantage Program.

If you get out-of-network services, claims will be processed through the Medicare Advantage Program and paid according to the current rules established in the Medicare Advantage Program policies that apply.

We have a network of pharmacies outside our service area where you can purchase your prescription as a member. Generally, we cover drugs filled at a non-participating network pharmacy only when you cannot use a participating pharmacy.

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

Directorio
man

Apply now

your printed directory of suppliers

Request Directory

Organizational Determinations

The initial precertification determination is the starting point for meeting requests for coverage of health services that the member needs. Although certain services require preauthorization, there are organizational determinations that are not subject to that requirement. All these determinations are processed by the Triple-S Advantage Clinical Operations team, in compliance with current standards and requirements. In this way, we ensure that both pre-clearance and non-pre-clearance requests are handled appropriately and in accordance with established guidelines.

Who can request an Initial Determination?

The member, his or her doctor, or anyone the member designates as an authorized representative may request an initial determination. This means that you can choose a relative, friend, caregiver, doctor, or anyone else to act on your behalf. If this person is not already authorized by state law, the member and that person must sign and date an appointment of representative form. This way, that person will have legal permission to officially represent you.

What do I need to request an Initial Determination?

The minimum requirements to work on your application are:

  • Full Name
  • Contract number
  • Medical order (including date, signature, and license number of the ordering physician)
  • Clinical justification for the requested service
  • Codes for Diagnostics, Procedures, and Services
  • Results of previous studies or laboratories (if applicable)
  • Referrals (if applicable)

All this information must be faxed to one of the following numbers: send the order via facsimile to TSA (787-620-0925 or 0926).

What is the Initial Determination process like?

Once the doctor determines medical necessity for a certain study, service, or procedure that the member needs, he or she will send the order via facsimile to TSA (787-620-0925 or 0926). Our Triple S Advantage clinical staff will review and process the application, and if additional information is required, our clinical staff will contact the physician and member.

Some criteria used when evaluating your precertification application:

  • The severity of the condition
  • The adequacy of services
  • Medical justification for the requested service
  • Results of studies and laboratories relevant to the requested service
  • Clinical guidelines based on medical evidence
  • Internal medical policies

To comply with pre-authorization requirements, we rely on various guidelines and regulations. We use National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as well as Traditional Medicare laws in our region. We also evaluate whether the requested service is reasonable and necessary for your diagnosis or treatment, taking into account your medical history, health status, clinical notes and your doctor's recommendations.

If there are no specific coverage criteria in laws or regulations, Medicare Advantage (CMS) allows us to create internal policies based on medical evidence. In addition to our own policies, we may use recognized guidelines, such as the InterQual criteria or other guidelines from private agencies, governments, or professional organizations.

All the guidelines we use are publicly available on the Triple-S public website, so they can be easily accessed by both members and providers.

If it is the member who requests an expedited initial determination without the support of a physician, we will evaluate whether their health requires an expedited initial determination based on the severity of the patient's condition.

If we determine that your medical condition does not meet the requirements for an initial determination, we will send you a letter telling you how to file a grievance. You have the right to file a grievance if you disagree with our decision not to consider your request.

When the service meets the criteria, once authorized, the member is contacted by phone, and the letter is sent by postal mail. In addition, the authorization letter is sent to the provider via fax or postal mail. The pre-certification will be valid for a certain time depending on the type of service.

If the request is not approved, the respondent will receive a letter with the reasons and information about his or her right to appeal.

Triple S will inform you of its determination as soon as your health condition requires, and in no event later than 72 hours for expedited (urgent) cases or 7 days for standard cases. For other items and/or services that do not require pre-authorization, notification will be made within a maximum of 14 days. And for drugs covered under Part B, we'll notify you within 72 hours for standard requests, and within 24 hours for expedited (urgent) cases.

Pre-authorization Referral Form

Medicare Advantage medical policies and internal coverage criteria

To access the Medicare Advantage medical policies and internal coverage criteria please access the following links:

I wish to receive information about the coverage products and services offered by Triple-S Advantage

You have:

By completing this form, you agree to a meeting with a sales agent to discuss the types of products you check above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

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.