​Individual Care Management Program

We wish to inform you about our Individual 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 the members by implementing an individualized 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 based on the treatment defined by your doctor.

The Individual Care Management Program is free of charge, 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 you begin your voluntary participation in this program, you may choose to unsubscribe at any time.

There are specialized health services that require prior authorization by the Precertification Program. Please refer to your policy explanation of benefit for more details.

It should be noted that health services that require pre-authorization must be requested through a medical order from your primary care physician or specialist, justifying the medical necessity of the service.

Eligible Members

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

• Member with End Stage Renal Disease (ESRD), without fistula coordination)
• Members eligible for organ and/or bone marrow transplantation
• Home health services: nursing care, IV therapy, physical, occupational, or speech therapy, home nutritionist visit, or doctor visit
• Members who require services in the United States, as they are not available in Puerto Rico.
• Members with multiple chronic or terminal illnesses
• Hospice services
• Skin care (for example, chronic ulcers)
• Members with special medications
• Malignancies (cancer)
• Complications related to chronic conditions, such as congestive heart failure, kidney disease, and stroke
• Members dependent on a mechanical ventilator
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Member with multiple chronic or terminal illnesses

If you need additional information or if the need arises for a referral to our Care Management Program, you can contact the Customer Service Call Center by calling 787.281.2800 (metro area) or 1.888.758.1616 (toll-free), Monday through Friday from 8:00 a.m. to 5:00 p.m. to 8:00 p.m. and Saturdays from 8:00 a.m. to 5:00 p.m. to 4:30 p.m. The hearing impaired (TTY) may contact 1.866.627.8182.

Services in the United States

The member’s health plan coverage includes emergencies in the United States, as well as medical services that are not available in Puerto Rico and have been previously coordinated or pre-authorized by MCS. Emergencies do not require precertification or pre-authorization.

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 policy or benefit certificate or contact our Customer Service Call Center at 787.281.2800 (metro area) or 1.866.758.1616 (Toll Free).

To access services in the United States

Identify the service you are going to receive:

1. Emergency Services. These services do not require precertification or pre-authorization. Just present your plan card and the facility will verify your eligibility with MCS.
2. Services that are not emergencies and that are not available in Puerto Rico.

• Require precertification or pre-authorization:
  Before receiving services, you must contact our Customer Service Call Center and submit all necessary information in writing. We will then refer the case to the Care Management Unit so that one of our Care Management Specialists can assess the medical necessity of the requested services.


• Once our Care Management Specialist evaluates all the documentation submitted and determines if it meets the medical necessity criteria, 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 applicable provider network in the location you will visit in the United States.


• At the time of receiving pre-certified or pre-authorized services in the United States, you will pay the corresponding coinsurance, as described in your policy or certificate of benefits. If you do not pre-certify or pre-authorize the services in the United States, the terms and conditions described in your policy or certificate of benefits 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 their policy or certificate of benefits 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. In case 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 insured's eligibility through our Provider Services Call Center in Puerto Rico by calling 1.800.981.4766 (toll-free).

Precertification of Services and Procedures

Some health services require precertification. Learn all about them here. Our Precertification Program evaluates your request for services, whether it is a study or procedure before they are carried out. Precertification Unit validates your medical necessity and prevents risks for beneficiaries, in addition to promoting stability and consistency in medical determinations.

The following criteria are used when evaluating your precertification request:

• The severity of the condition
• The intensity of the services
• The medical justification for the requested service
• Clinical Guide based on medical evidence
• Internal Medical Policy
• Medical Advisors

The minimum requirements to work your application are:

• Full name of the patient
• Contract number
• Medical order (including all the clinical justification necessary to make a decision)
• Diagnosis and Service Codes (ICD10, CPT, HCPCS)
• Previous studies or laboratories (if applicable)
• Referrals (if applicable)

All this information must be received by fax: 787-620-1336, 787-622-2434, 787-622-2436

Services that require precertification

The services or procedures that require precertification vary according to your line of business and the policy. It is important to check with the Customer Service or Provider Service Department in case of doubt whether the services require pre-certification.

Services that require precertification, varies by coverage:

• Magnetic Resonance Imaging (MRI)
• Computed Tomography (CT Scan)
• Positron Emission Tomography (PET Scan)
• Durable Medical Equipment
• Home Health Care
• Among others