If your doctors or your Insurer make a decision about your care that you don’t agree with, you can file an appeal. When you appeal, you’re asking your Insurer to take another look at a mistake you think was made.
If your Insurer denies, reduces, limits, suspends, or ends your health care services, they will send you a letter in the mail. The letter will have information like:
What decision your Insurer made
Why they made the decision
How to file an appeal
If you don’t agree with the decision, you can file an appeal. You have 60 days from the date of the letter to file an appeal. Your doctor or your representative can file the appeal for you if you authorize them to do so.
There are many ways to file an appeal. You can:
Call your Insurer at 1-844-336-3331(toll free), TTY 787-999-4411 (for the hearing impaired)
Visit any of your Insurer’s service centers
Mail your Insurer your appeal at MMM Multi Health, G&A DEPT, PO BOX 72010, San Juan PR 00936
Your appeal will be reviewed by a team of experts that have not been involved with the issue of your appeal. Your Insurer will make a decision within 30 days. If you have an emergency and your Insurer agrees that you do, you can ask for an expedited or fast appeal. You, your doctor, or your representative can ask for a fast appeal by calling your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) or visiting any of your Insurer’s service centers, or writing a letter to your Insurer at MMM Multi Health, G&A DEPT, PO BOX 72010, San Juan PR 00936-7710
If your Insurer agrees to give you a fast appeal, they will decide your case within 72 hours. If your Insurer does not agree to give you a fast appeal, they will call you within 2 days to let you know they will decide your case within 30 days.
If your Insurer can’t make a decision within 30 days, they can ask for up to 14 more days. If they ask for more time, they have to let you know why. If you do not agree to give your Insurer more time, you can file a complaint.
ASES may choose to make available to Providers any appeals rights to challenge the failure of your insurer to cover a service.
Once your Insurer makes a decision, they will send you a letter within 2 business days. The letter will tell you what they decided and that you have the right to ask for a hearing if you do not agree with the decision.
If you are not happy with your Insurer’s decision about a complaint or an appeal, you can ask for a hearing. A hearing is where you can tell an Official Examiner about the mistake you think your Insurer made. You have 120 days from the date of your Insurer’s decision to ask for an Administrative Hearing with ASES.
You can get more information about hearings or request a hearing by:
Calling the Vital Plan call center at:
1-800-981-2737
Writing ASES at:
ASES
PO Box 195661
San Juan, PR 00919-5661
Sending ASES a fax to:
787-474-3347
Before the hearing, you and your representative can ask to look at the papers and records that your Insurer will use. Your Insurer must give you access to those papers and records for free.
During the hearing, you can give facts and proof about your health and medical care. An Official Examiner will listen to everyone’s side. At the hearing, you can talk for yourself or you can bring someone else to talk for you like a friend or a lawyer.
The Official Examiner will decide your case within 90 days. If you need a fast decision, the Official Examiner will decide your case within 72 hours.
If you do not agree with the Official Examiner’s decision, you can file an appeal with the Court of Appeals of Puerto Rico. More information about how to file an appeal will be in the papers you get after the hearing.
If you are already getting services, you may be able to keep getting services during your appeal or hearing. To keep getting services, all of these things must be true:
You file the appeal within 60 days of the date on the letter from your Insurer.
You ask to keep getting services by the date your care will stop or change or within 10 days of the date on the letter from your Insurer (whichever date is later).
You say in your appeal that you want to keep getting services during the appeal.
The appeal is for the kind and amount of care you’ve been getting that has been stopped or changed.
You have a doctor’s order for the services (if one is needed).
The services are something that Vital Plan still covers.
If you keep getting services during your appeal or hearing and you lose, you might have to pay your Insurer back for the services you got during the appeal or hearing process.
To ask to keep getting services during your appeal or hearing, call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).
