Prior authorization of services and procedures

Some health services require prior authorization before the service is provided. Our clinical staff in the Prior Authorization Unit evaluates the requests for these services. The unit validates your benefits coverage and medical necessity by preventing risks and ensuring you receive appropriate, high-quality services.

Benefit determinations

The benefit determination (prior authorization) is the starting point for handling requests you or your physician may have about covering a health service or care you need. Benefit determinations about medical care or covered services must be requested before the service is provided. This process applies to all procedures, studies, items, and services that require prior authorization. MCS Life will not be responsible for paying for services received or rendered without prior authorization, except in cases of emergency, as established under Law No. 194 of August 25, 2000.

Who can request a prior authorization?

You, your doctor, service provider, or someone you designate as an authorized representative can request a prior authorization. You may designate a family member, friend, advocate, physician, or any other person to act on your behalf. If you would like someone who is not currently authorized under state laws to act on your behalf, both you and that person must sign and date the Appointment of Representative Form, which will grant that person the legal authority to be your authorized representative. To download the form, click . here.

If you need additional information or verifications about benefit coverage, you can contact the Customer Service Call Center at 787-281-2800 (metro area) or at 1-888-758-1616 (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 impairments (TTY) can contact us at 1-866-627-8182.

Services that require prior authorization

The services or procedures that require prior authorization may vary according to your benefit coverage. It is important to contact the Customer Service Department if you have questions about whether a service requires prior authorization or if benefit limits apply.

Some examples of services that may require prior authorization are (they may vary by coverage) :

• Certain advanced imaging studies
• Certain surgical procedures
• Durable medical equipment (DME)
• Home care services

Some of the criteria used when evaluating your prior authorization request include :

• The severity of the health condition
• Whether the requested services are appropriate for your medical needs
• Medical justification for the requested service
• Results of diagnostic studies and laboratory tests relevant to the requested service
• Clinical guidelines based on scientific evidence

The minimum requirements to process your request are:

• Full name
• Contract number
• Medical order (including date, signature and license number of the ordering physician)
• Diagnostic, procedure, and service codes
• Clinical justification or evaluation for the requested service
• Previous diagnostic studies or laboratory results (if applicable)

When the required service meets all the established criteria, you and your provider will be informed by telephone and/or mail. The prior authorization will remain valid for a specific period of time, depending on the requested service.

If an adverse determination is issued, a letter will be sent to you and your provider detailing the reasons for the adverse determination. This letter will also inform you of your right to appeal the decision.

How can I request a prior authorization?

You, your doctor, provider, or authorized representative can request prior authorization by contacting the Customer Service Call Center at 787-281-2800 (metro area) or 1-888-758-1616 (toll-free) or TTY 1-866-627-8182 (for people with hearing impairments). Our service hours are 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. You can also request a prior authorization by completing the Prior Authorization Request Form, with the assistance of your doctor and sending it via fax to 787-622-2434, 787-622-2436 or 787-620-1336.

Standard or expedited prior authorization requests

The request you, your physician, provider, or your authorized representative make for a prior authorization can be considered standard or expedited (urgent). Expedited or urgent requests should be requested if your physician determines that your health or ability to function could be seriously affected or endangered if you do not receive the requested service promptly.

If your physician requests or supports an expedited prior authorization request on your behalf, your request will be processed quickly. For an expedited request, we will provide you with our determination about the medical care or services you requested within 24 hours of receiving your request. If we need more information, such as your medical records, we will notify you with at least one (1) phone attempt about the deficiency within 24 hours and give you no less than 48 hours to submit the additional information. The final determination will be made within 48 hours after receipt of the additional information or after the deadline provided to submit the additional information requested.

If your request is standard, we will make a determination within 15 days of receiving your request, or within 72 hours if you have a cancer diagnosis. If we need more information, such as your medical records, we will notify you with at least one (1) phone attempt about the deficiency before the initial 15-day period and give you no less than 45 days to submit the additional information. The final determination will be made after receipt of the additional information or after the deadline provided to submit the additional information requested.

Criteria and policies

MCS Life requires prior authorization for certain reasonable and necessary items and services for health diagnosis and treatment. As part of the prior authorization process, we evaluate whether the item or service requested is included as covered in your benefit policy. If the item or service is covered and requires prior authorization, we base decisions on clinical guidelines and medical policies based on scientific evidence and the general conditions of coverage and benefits established by the laws of Puerto Rico.