Reimbursement Policy - Medical Expenses

What is a payment determination or reimbursement?

A determination of payment is any determination made by MCS, whether an approval or denial. A reimbursement is the request to receive all or part of the money that was disbursed by the member for a medical or dental service.

How can you request a Reimbursement?

Receipts for reimbursement must be legible and must include the following information:

• Original official receipt - The original receipt must have the logo or seal of the service provider. This receipt must contain the provider’s name, address, phone number and specialty.
• National Provider Identifier (NPI) number, Employer Identification Number and State License Number.
• Complete name of member.
• Contract number of member.
• Date of service (month / day / year).
• Description of the service received - If the receipt is for more than one service, each service must be detailed. Laboratory receipts must specify all lab tests conducted to the patient.
• Enter the code (number that identifies the diagnostic - ICD-10) and description of the diagnosis.
• Indicate the paid cost of each detailed service.
• The receipt must indicate the tooth or the workpiece (only applies to Dental).
• Include side of the work piece - Each surface has separate fee (only applies to Dental).

Note: Individual cash receipts, canceled checks, receipts for money orders, personal breakdowns and invoices indicating only “Balance Due” are not acceptable. Forms that do not contain the requested information may delay the processing of your refund or be returned to you.

You or an authorized representative must send your written request by mail to the following address:

MCS Advantage, Inc.
Attention: Claims Department
P O Box 191720
San Juan, PR 00919-1720

If you need information or assistance, you can call us at:
Toll free: 1-866-627-8183
TTY/TDD only: 1-866-627-8182