Providers

Organization Determinations

The initial precertification determination is the starting point for addressing requests for coverage of health services that the member needs. Although certain services require prior authorization, there are organization 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 regulations and requirements. In this way, we ensure that both requests requiring prior authorization and those that do not are handled appropriately and in accordance with established guidelines.

Who can request an Initial Determination?

The member, their physician, or any person the member designates as an authorized representative can request an initial determination. This means you can choose a relative, friend, caregiver, physician, or any other person to act on your behalf. If this person is not already authorized by state laws, 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 process your request are:

• Full name
• Contract number
• Medical order (including date, signature, and license number of the ordering physician)
• Clinical justification for the requested service
• Diagnosis, procedure, and service codes
• Results of previous studies or laboratories (if applicable)
• Referrals (if applicable)

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

What is the Initial Determination process?

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

Some criteria used when evaluating your precertification request:

• The severity of the condition
• The appropriateness of the services
• The 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 meet prior authorization requirements, we rely on various guidelines and regulations. We use National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), 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 physician’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 can use recognized guidelines, such as InterQual criteria or other guidelines from private agencies, government agencies, or professional organizations.

All clinical guidelines we use are publicly available on the Triple-S portal, so that both members and providers can easily consult them.

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 according to 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 informing you how to file a grievance. You have the right to file a grievance if you do not agree 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 portal mail. In addition, the authorization letter is sent to the provider via fax or postal mail. The precertification will be valid for a determined time according to the type of service.

If the request is not approved, the member will receive a letter with the reasons and information about their right to appeal.

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

Payment Dispute for Non-Contracted Providers

A payment dispute is a disagreement between a non-contracted provider and the Medicare Advantage Organization about the amount or level paid for a service covered by Medicare. The non-contracted provider will have 120 days from the initial determination to request the dispute.

What do you need to do to request a payment dispute?

The non-contracted provider can request the dispute by sending the following forms with the necessary documentation to the following address:

Non-Participating Provider Dispute Form
Waiver of Liability

Triple-S Advantage, Inc.
Claims Department
Re: Provider Payment Dispute
PO Box 11320
San Juan, Puerto Rico 00922-1320

Payment Reconsideration Request for Non-Participating Providers

What do you need to do to request payment reconsideration?

The non-contracted provider can request a payment reconsideration 60 days from the date of payment or denial, by sending the following forms with the necessary documentation to the following address:

Reconsideration Letter
Waiver of Liability

Triple-S Advantage, Inc.
Grievances & Appeals Unit
Re: Payment Reconsideration-Non-Participating Providers
PO Box 11320
San Juan, Puerto Rico 00922–1320