Providers

Organizational Determinations

All organizational determinations (preauthorizations) are processed by the Medical Management staff at Triple-S Advantage, according to Medicare requirements. Triple-S Advantage 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 (for standard cases). The Medical Management staff is trained to process and respond to organizational determination requests.

Once the physician determines medical necessity for an assessment or procedure:

• The physician should send the medical order by fax to Triple-S Advantage at 787-620-0925 or 0926
• The order is processed and reviewed by the Medical Management staff
  • If additional information is required, our personnel will contact the physician or the member to obtain it
• Once the order is approved, we will contact the member by phone and send the authorization letter by mail
• The provider will also receive the authorization letter by fax

Payment dispute for non-contracted providers

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

What do you need to do to file a non-contracted payment dispute?

The non-contracted provider can file a dispute by sending the following forms with the necessary supporting documentation to the address listed below:

Non-Contracted Provider Payment 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 may request a payment reconsideration 60 days from the date of payment or denial by submitting the following forms with the necessary documentation to the following address below:

Reconsideration Letter
Reconsideration Documents
Waiver of Liability

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