If you are not happy with the care that you are getting, call us at\u00a0<\/span>1-800-981-1352<\/span><\/a>, TTY\/TDD users should call 1-855-295-4040<\/a><\/span>. Tell us that you need to make a complaint. You can also visit our\u00a0<\/span>Service Centers<\/span><\/a>. You can make a complaint at any time.<\/span><\/p>\n Your doctor, a family member, or your representative can make a complaint for you if you authorize them to do so.<\/span><\/p>\n You also have the right to call the Patient Advocate Office to make a complaint. Their number is\u00a0<\/span>1-800-981-0031<\/span><\/a>. You can also make a complaint to ASES. Their number is\u00a0<\/span>1-800-981-2737<\/span><\/a>.<\/span><\/p>\n No one can do anything bad to you if you make a complaint.<\/span><\/p>\n We have 72 hours to fix your complaint. If we can\u2019t fix your complaint quickly, it will become a \u201cgrievance\u201d. In this case, we have up to 90 days to fix it, but we must decide faster if it\u2019s important to your health. We must tell you how the complaint was fixed.<\/span><\/p>\n If we do not fix your complaint, you can ask for a hearing. A hearing is where you can tell a judge about the issue.<\/span><\/p>\n If your doctors or Triple-S Salud decide something about your care that you don\u2019t agree with, you can file an appeal. When you appeal, you\u2019re asking Triple-S Salud to take another look at a mistake you think was made.<\/span><\/p>\n If Triple-S Salud denies, reduces, limits, suspends, or ends your health care services, they will send you a letter in the mail. The letter will have information like:<\/span><\/p>\n If you don\u2019t agree with the decision, you can file an appeal. You have 60 days from the date of the letter to file an appeal. Your doctor or your representative can file the appeal for you if you authorize them to do so.<\/span><\/p>\n There are many ways to file an appeal. You can:<\/span><\/p>\n Your appeal will be reviewed by a team of experts that have not been involved with the issue of your appeal. Triple-S Salud will make a decision within 30 days. If you have an emergency and Triple-S Salud agrees that you do, you can ask for an expedited or fast appeal. You, your doctor, or your representative can ask for a fast appeal by calling Triple-S Salud at\u00a0<\/span>1-800-981-1352<\/span><\/a>; <\/span>TTY\/TDD users should call 1-855-295-4040<\/a><\/span>, by visiting any of Triple-S Salud service centers, or by writing a letter to your Insurer at:<\/span><\/p>\n Triple-S Salud, Inc<\/span> If Triple-S Salud agrees to give you a fast appeal, they will decide your case within 72 hours. If Triple-S Salud does not agree to give you a fast appeal, they will call you within 2 days to let you know they will decide your case within 30 days.<\/span><\/p>\n If Triple-S Salud can\u2019t decide within 30 days, they can ask for up to 14 more days. If they ask for more time, they must let you know why. If you do not agree to give your plan more time, you can file a complaint.<\/span><\/p>\n Once Triple-S Salud makes a decision, they will send you a letter within 2 business days. The letter will tell you what they decided and that you have the right to ask for a hearing if you do not agree with the decision.<\/span><\/p>\n If you are not happy with Triple-S Salud decision about a complaint or an appeal, you can ask for a hearing. A hearing is where you can tell an Official Examiner about the mistake you think Triple-S Salud made. You have 120 days from the date of Triple-S Salud decision to ask for an Administrative Hearing with ASES.<\/span><\/p>\n You can get more information about hearings or request a hearing by:<\/span><\/p>\n Calling the Vital call center at: 1-800-981-2737<\/a>; TTY \/ TDD users should call 787-474-3389<\/a>.<\/p>\n Writing ASES at: ASES PO Box 195661 San Juan, PR 00919-5661<\/p>\n Sending ASES a fax to: 787-474-3346<\/a><\/p>\n Before the hearing, you and your representative can ask to look at the papers and records that Triple-S Salud will use. Triple-S Salud must give you access to those papers and records for free.<\/span><\/p>\n During the hearing, you can give facts and proof about your health and medical care. An Official Examiner will listen to everyone\u2019s side. At the hearing, you can talk for yourself, or you can bring someone else to talk for you like a friend or a lawyer.<\/span><\/p>\n The Official Examiner will decide your case within 90 days. If you need a fast decision, the Official Examiner will decide your case within 72 hours.<\/span><\/p>\n If you do not agree with the Official Examiner\u2019s decision, you can file an appeal with the Court of Appeals of Puerto Rico. More information about how to file an appeal will be in the papers you get after the administrative hearing.<\/span><\/p>\n If you are already getting services, you may be able to keep getting services during your appeal or hearing. To keep getting services, these things must be true:<\/span><\/p>\n If you keep getting services during your appeal or hearing and you lose, you might have to pay Triple-S Salud back for the services you got during the appeal or hearing process.<\/span><\/p>\n To ask to keep getting services during your appeal or hearing, call Triple-S Salud at\u00a0<\/span>1-800-981-1352<\/span><\/a>; <\/span>TTY\/TDD users should call 1-855-295-4040<\/a>\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":" NEED TO MAKE A COMPLAINT ABOUT YOUR CARE? If you are not happy with the care that you are getting, call us at\u00a01-800-981-1352, TTY\/TDD users should call 1-855-295-4040. Tell us that you need to make a complaint. You can also visit our\u00a0Service Centers. You can make a complaint at any time. Your doctor, a family […]<\/p>\n","protected":false},"author":7,"featured_media":917,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/page-tabs-content.php","meta":{"footnotes":""},"class_list":["post-27","page","type-page","status-publish","has-post-thumbnail","hentry"],"yoast_head":"\nWHAT HAPPENS IF MY COMPLAINT ISN\u2019T FIXED?<\/h4>\n
WHAT IS AN APPEAL?<\/h4>\n
\n
\n
\n<\/span>
\nTriple-S Salud, Inc
\nGrievances and Appeals Department
\nPO Box 11320
\nSan Juan, P.R., 00922-1320<\/li>\n<\/ul>\nWHAT WILL HAPPEN WHEN MY MCO GETS THE APPEAL?<\/h4>\n
\n<\/span>Grievances and Appeals Department<\/span>
\n<\/span>PO Box 11320
\n<\/span>San Juan, P.R., 00922-1320<\/span><\/p>\nWHAT CAN I DO IF I DON\u2019T AGREE WITH THE DECISION?<\/h4>\n
CAN I KEEP GETTING SERVICES DURING MY APPEAL OR HEARING?<\/h4>\n
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