Care Management Program

We want to inform you about our 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 your primary care physician or specialist. We direct our efforts to improve your quality of health care 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 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 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
• Members who need skin care due to chronic ulcers
• Members who use specialty drugs
• 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 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. People with hearing impairment (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. People with hearing impairment (TTY) can call 1.866.627.8182.

For Access to services in the United States

Identify the Service you need:

1. Emergency Services These services do not require precertification or preauthorization. You only need to present your health plan card and the facility will verify your eligibility with MCS.
2. Services that are not emergencies and are not available in Puerto Rico.
• A prior authorization is required.
• Prior to receiving services, you should contact our Customer Service Call Center for guidance.
• All necessary information must be received in writing, you can request assistance from your physician. Our clinical staff will evaluate the received documentation.
• Once our care management specialist evaluates the submitted documentation, determines if it meets the medical necessity criteria, and validates your coverage for services in the United States, we will proceed to coordinate the services and issue a prior authorization. This will be sent to the service provider available through the applicable provider network in the location you will visit in the United States
• At the time you receive the authorized services in the United States, you will pay the corresponding coinsurance as described in your evidence of coverage. If you do not have an authorization to receive 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 services in addition to emergencies and services not available in Puerto Rico, must 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 provider network 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 787.620.2535 (metro area) or 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. People with hearing impairment (TTY) can call 1.866.627.8182.