Individualized Care Management Program

We support you even more when your health is a stake

We want to inform you about our Individualized Care Management Program, under which we work with the population that suffers from chronic, catastrophic, degenerative, and disabling conditions.

Through this clinical program, we coordinate and facilitate the care and services related to the participant's condition by following up on the treatment plan established by their primary care physician or specialist. We direct our efforts to improve the quality of health care for members through an individualized care plan.

If you need our support, you will have nursing staff and care management specialists, who will contact you periodically by phone to monitor the progress of your treatment. The purpose of this management is to identify your individual needs and help you achieve the goals and objectives developed in accordance with the treatment plan defined by your doctor.

The Individualized Care Management Program is free, voluntary, and available to any member who qualifies. You can apply directly for program services by contacting the Customer Service Call Center. Your call will be confidential. Once your voluntary participation in this program begins, you may opt out at any time.

Eligible Members

Below, we share a list of the conditions and situations that are indicators to be referred to the Individualized Care Management Program:

Members with end-stage renal disease (ESRD), without fistula coordination
Members eligible for organ and/or bone marrow transplantation
Members who require services in the United States because they are not available in Puerto Rico.
Members with multiple chronic or end-stage illnesses
Skin care (for example, chronic ulcers)
Members with specialty drugs
Malignancies (cancer)
Complications related to chronic conditions, such as congestive heart failure, kidney disease, and stroke.
Members dependent on a mechanical ventilator

If you need additional information or if a referral to our Individualized Care Management Program arises, you can contact the Customer Service Call Center by calling 787.620.2530 (metro area) or 1.866.627.8183 (toll free)., Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturdays from 8:00 a.m. to 4:30 p.m. The hearing impaired (TTY) can call 1.866.627.8182.

Services in the United States

Your coverage includes emergency services in the United States, as well as medical services that are not available in Puerto Rico and have been previously coordinated or preauthorized by MCS. Emergencies do not require precertification or preauthorization.

Important Note: The information in this section is intended to serve as a general instruction guide. For more detailed information about your benefits in the United States, you should refer to your evidence of coverage or contact our Customer Service Call Center at 787.620.2530 (metro area) or 1.866.627.8183 (toll free), Monday to Friday from 8:00 a.m. to 8:00 p.m. and Saturdays from 8:00 a.m. to 4:30 p.m. The hearing impaired (TTY) can call 1.866.627.8182.

For Access to services in the United States

Identify the Service you need:

Emergency Services These services do not require precertification or preauthorization. All you have to do is present your plan card and the facility will verify your eligibility with MCS.
Services that are not emergencies and are not available in Puerto Rico.
- Require precertification or preauthorization:
- Prior to receiving services, you must contact our Customer Service Call Center for guidance. All necessary information must be received in writing for the case to be referred to the Care Management Unit. One of our specialists will assess the medical necessity of the requested services.
- Once our specialist in care management evaluates all the documentation submitted, determines if it meets the criteria of medical necessity and verifies the evidence of coverage in the United States, we will proceed to coordinate the services and issue a pre-authorization or pre-certification. This will be sent to the service provider available through the provider network applicable in the location you will visit in the United States.
- At the time you receive the precertified or preauthorized services in the United States, you will pay the corresponding coinsurance as described in your evidence of coverage. If you do not precertified or preauthorize services in the United States, the terms and conditions described in your evidence of coverage will apply.

Members under products whose coverage in the United States includes additional services to emergencies and services not available in Puerto Rico, should consult the evidence of coverage for detailed information. You can identify the provider network in the United States and their contact information on the back of your health plan card. If you have a separate card to access services in the United States, it will also have information about your network of providers in the United States and their contact information.

The service provider in the United States can verify the member's eligibility through our Provider Service Call Center in Puerto Rico by calling 1.800.981.4766 (toll free), Monday to Friday from 8:00 a.m. to 8:00 p.m. and Saturdays from 8:00 a.m. to 4:30 p.m. The hearing impaired (TTY) can call 1.866.627.8182.