Some health services require pre-certification before the service is provided. Our Precertification Program clinical staff evaluates the requests for these services. The precertification unit validates your medical necessity by preventing risks and ensuring that you receive adequate and quality services.
The initial determination (pre-certification) is the starting point for dealing with requests that you or your provider may have about covering a service or the health care you need. The initial determination about your Part C medical care or service are called "Organization Determinations" and must be requested before the service is provided.
You, your provider, or somebody that you have designated may ask us for an initial determination. 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. You are also entitled to have an Attorney act on your behalf. If you would like for someone who is not yet authorized under the state laws to act on your behalf, then, both you and that person must sign and date the Appointment of Representative, which will grant that person the legal authority to be your authorized representative. To download the form click here.
After completing the form, you must send it to the following address: MCS Advantage, P.O. Box 191720 San Juan, P.R. 00919-1720 or via fax at 787-620-1336.
For any questions about how to request an initial determination of medical care or services under Part C, you may call us at 1-866-627-8183 (Toll free) o al 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.
The services or procedures that require precertification may vary according to your evidence of coverage. It is important to validate with the Customer Service or Provider Service Department in case of doubt whether the services require pre-certification.
Some examples of services that require precertification are (remember they may vary by coverage):
Some criteria used when evaluating your precertification request:
The minimum requirements to work your request are:
All this information must be sent by fax to any of the following numbers: 787.620.1336, 787.622.2434, 787.622.2436
When the required service meets all the established criteria, both you and your provider will be informed by telephone and/or mail. The precertification will be effective for a certain time, depending on the requested service.
When the service request is unfavorable, a letter will be sent to you and your provider detailing the reasons for the adverse determination. In the same letter, you will be informed of your right to appeal the decision.
You, your physician, or your authorized representative may request an initial determination by contacting the Service Call Center MCS Classicare, al 1-866-627-8183 (Toll free) o al 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. You may also send your request by fax at 787-620-1336 or by mail to the following address: MCS Advantage, Inc., P.O. Box 191720 San Juan, P.R. 00919-1720. You can also request an initial determination by completing the Pre-certification Request formulary, with the help of your doctor, and faxing it to 787.620.1336, 787.622.2434 o 787.622.2436.
The request made by you or your doctor for an initial determination may be considered standard or expedited (fast). Expedited or expeditious determinations should be requested when you or your doctor determine that your health or ability to function could be seriously harm if you do not receive the requested service promptly.
If your physician requests or supports you in requesting an expedited initial determination, your request will be handled quickly. If you are the one requesting an expedited initial determination without your physician support, we will consider whether your health requires an expedited initial determination. If we determine that your medical condition does not meet the requirements for an expedited initial determination, we will send you a letter informing you how to file an expedited grievance and we will handled your request as a standard one. You have the right to file an expedite grievance if you disagree with our decision to deny your request for an expedite review.
If your request is standard, we will be making an initial determination no later than 14 days after receiving your request. However, we may require up to 14 additional days if you request additional time or if we need more information (such as medical records) that may benefit you. If we require the additional days, we will notify you in writing. If you understand that we should not take additional days, you can file an expedited complaint.
For an expedited request we will provide our determination about the medical care or services within 72 hours after receiving your request. However, we may take up to an additional 14 days if we need more information (such as medical records) that may benefit you, or if you need more time to prepare for this review. If we require additional days, we will notify you in writing. If you understand that we should not take additional days, you can file an expedited complaint.
In addition to filing a complaint directly with MCS, you have the option of filing a complaint with Medicare by visiting Medicare.gov/grievance
As part of the preauthorization requirement, we use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and the general conditions of coverage and benefits included in the Traditional Medicare laws in our region. In addition to the coverage and benefits, we evaluate that the requested item or service is considered reasonable and necessary for the diagnosis and treatment of your health conditions, using your medical history, functional status, clinical notes, and recommendations from your doctor. Medical necessity determinations are based on the specific individual circumstances of each individual.
When coverage criteria are not established by the applicable Medicare statutes, regulations, NCDs, or LCDs, CMS allows us to create internal policies using evidence-based medical sources. In addition to our internal policies, we may use other recognized supporting guidelines based on medical evidence, such as InterQual® criteria or nationally accepted guidelines from private and government agencies and professional organizations.
MCS makes all these criteria publicly available for anyone who wants to view them. The links to the resources are below:
MCS delegates some services to independent entities, First Healthcare (FHC) for mental health services and Netclaims for dental services. These entities also conduct the medical necessity review for these services. To consult the clinical criteria used by these entities follow the links below.
If you are a new member to MCS Classicare we will cover a transition period during the first ninety (90) days of your membership in the plan to receive your active item or services with your previous plan. To ensure your continuity of care, it is important to provide a copy of the approval letter for the item or service provided by your previous plan. This only applies to the basic benefits and not to the complementary benefits. For more details, you can refer to the area How can I request an Initial Determination?