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Precertific​ation of Service​​s and Procedures
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    • Precertification of Services and Procedures

    Some health services require precertification before the service is provided. Our clinical staff in the Precertification Unit evaluates the requests for these services. The unit validates your benefits coverage and medical necessity by preventing risks and ensuring you receive adequate and quality services.

    Benefit determinations

    The benefit determination (precertification) is the starting point for handling requests you or your provider 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 will apply to all procedures, studies, items, and services that require precertification. MCS Life will not be responsible for payment of services received or rendered without precertification, except in cases of emergency, as established under Law No. 194 of August 25, 2000.

    Who can request an initial determination?

    You, your doctor, service provider, or someone you designate can request a precertification. The person you designate will be your Authorized Representative. 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. Hearing impaired individuals (TTY) can contact us at 1-866-627-8182.

    Services that require precertification

    The services or procedures that require precertification may vary according to your benefit coverage. It is important to validate with the Customer Service Department if you have doubts about whether a service requires precertification or has any established limits.

    Some criteria used when evaluating your precertification request include:

    • The severity of the condition
    • The adequacy of the services
    • The medical justification for the requested service
    • Results of studies and labs relevant to the requested service
    • Clinical guidelines based on medical evidence
    • Internal medical policies

    The minimum requirements to work your request are:

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

    All this information must be sent by fax to any of the following numbers: 787.622.2434, 787.622.2436, or you can call the Customer Service Call Center at 787-281-2800.

    When the required service meets all the established criteria, you and your provider will be informed by telephone and/or mail. Depending on the requested service, the precertification will be effective for a specific period.

    When the service request is unfavorable, 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 an initial determination?

    You, your doctor, provider, or authorized representative can request precertification 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 hearing impaired individuals). 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 an initial determination by completing the Precertification Request form, with the assistance of your doctor and sending it via fax to 787.622.2434, 787.622.2436 or 787.620.1336.

    Descargar PDF Precertific​ation Form

    Standard or expedited initial determination

    The request you, your physician, provider, or your authorized representative make for a precertification 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 you in requesting an expedited request, 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 determine within 15 days, or within 72 hours, if you have a cancer diagnosis, after 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 before the initial 15-day 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 precertification for certain reasonable and necessary items and services for health diagnosis and treatment. As part of the precertification 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 precertification, we base decisions on clinical guidelines and medical policies based on scientific evidence and the general conditions of coverage and benefits included in the laws of Puerto Rico.