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 service receipt, to the address or fax number shown below

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

All organization determination or prior authorization requests are processed by TSA Clinical Operations according to CMS requirements.

TSA will notify the member of its determination as expeditiously as the member’s health condition requires, but no later than 72 hours (for expedited determinations) or 14 calendar days after the date TSA receives the for a standard organization determination. TSA Clinical Operations is trained for processing and responding to organization determination requests.

Once the physician requests or determines medical necessity for a service, the medical order is sent with the proper/complete documentation by fax to (787) 620-0925 or 0926.

After this is received, dedicated teams of nurses will review the request and if there needs to be obtain more information, ordering physician is contacted to complete the request.

The member will received the approval by phone and mail and the provider will received by fax.

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.