We will send you a written decision explaining why we denied your request. If an Initial Determination does not provide you all that you requested, you have the right to appeal the decision.
You may ask us to review our Initial Determination, even if only part of our decision is not what you requested. An appeal to the Plan about Part C medical care or services is also called a Plan "Reconsideration"". When we receive your request to review the Initial Determination, the request is evaluated by a person who was not involved in making the Initial Determination.
If you are appealing an Initial Determination, you, your Authorized Representative, or your Doctor may file a standard appeal request or an expedite appeal request.
You or somebody that you have designated may ask us for a reconsideration. The person that you designate will be your "Authorized Representative." You may designate a family member, a friend, an intercessor, a physician, or any other person to act on your behalf. Other persons may already be authorized to act on your behalf under State Laws. If you would like for someone who is not yet authorized under the State Laws to act on your behalf, then both, you and said person must sign and date an Appointment of Representative, which will grant that person the Legal authority to be your Authorized Representative. You are also entitled to have an Attorney act on your behalf.
However, Providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a "Waiver of Liability" (WOL) statement, which provide, that the Non-Contract Provider will not bill you, regardless of the outcome of the Appeal.
You must make your appeal request within sixty-five (65) calendar days from the date on the written notice we sent to tell you our answer on the coverage decision.
Appeals request - about your Medical Care and Services
To request a standard appeal regarding Part C medical care or services, you, your Physician, or your Authorized Representative may visit any of MCS Service Centers or may call our MCS Classicare Customer Service Call Center at 1-866- 627-8183 (Toll free) or TTY 1-866-627-8182 (number for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. You may also send your request by fax at 787-620-7765, or by mail at the following address: MCS Advantage, Grievances & Appeals Unit, P.O. Box 195429, San Juan, P.R. 00919-5429.
If you are appealing a determination that we have made about providing you with a Part C medical care or service that you have not yet received, you and/or your Physician must evaluate whether you need an expedite appeal.
To request an expedite appeal from us, you can visit any of MCS Service Centers or call 1-866-627-8183 (Toll free) or at TTY 1-866-627-8182 (number for the hearing-impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. You may also send your request by fax at 787-620-7765, or by mail at the following address: MCS Advantage, Grievances & Appeals Unit, P.O. Box 195429, San Juan P.R. 00919-5429.
Make sure to request an "expedite" appeal. If your doctor requests an expedite appeal for you, or supports you in asking for one, and the Doctor indicates that waiting for a standard appeal could seriously harm your health or your ability to function, we will automatically expedite your appeal.
If you request an expedite appeal without the support from a Doctor, we will decide if you require an expedite appeal. If we decide that your medical condition does not meet the requirements for an expedite review, we will send you a letter informing you that if you get a Doctor's support for an expedite review, we will automatically expedite your appeal. The letter will also provide you orientation in how to file an "expedite grievance." You have the right to file an expedite grievance if you disagree with our decision to deny your request for an expedite review. If we deny your request for an expedite appeal, we will give manage your request as a standard appeal.
As a Member of MCS, you have the right to access information such as the number of Quality-of-Care Grievances and Appeals made by Members; the Plan’s performance ratings, including how it has been rated by Plan Members, and how it compares to other Medicare Advantage health plans.
If you are interested in any of this information, please call MCS Classicare Customer Service Call Center at 787-620-2530 (Metro area), 1-866-627-8183 (Toll free number) or TTY 1-866-627-8182 (for hearing impaired people). Our service hours are Monday through Sunday from 8:00 a.m. to 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m. Also, you can request it by fax at 787-620-7765 or by mailing to the following address: MCS Advantage, Inc., Grievances and Appeals Unit, P.O. Box195429, San Juan P.R. 00919-5429.
For more information about the process of requesting appeals, refer to your Evidence of Coverages, to the chapter titled: What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
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