Services in the United States

The members’ health plan coverage include emergencies in the United States, as well as medical services not available in Puerto Rico been previously coordinate and pre-certified or pre-authorized by MCS. Emergencies do not require pre-certification or pre-authorization.

Important Notice: The information contained within this section is intended to serve as a general instructions guide. For more detailed information regarding your benefits in the United States, you should refer to your policy or certificate of benefits, 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 will receive:

Emergency Services. These services do not require pre-certification or pre-authorization. Just show your plan ID card and the facility will verify your eligibility with MCS.
Non-emergency services and not available in Puerto Rico.

Require pre-certification or pre-authorization:

Prior to receiving services, you must contact our Customer Service Call Center and submit all necessary information, in writing. Then, your case will be referred to the Care Management Unit so that one of our Care Management Specialists can assess the medical need for the services requested.

Once our Care Management Specialist assesses the documentation submitted and determines whether 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 applicable coinsurance, as described in your policy or certificate of benefits. If you do not pre-certify or pre-authorize services in the United States, the terms and conditions described in your policy or benefits certificate will apply.

Members under products whose coverage in the United States include services other than emergencies and not available services in Puerto Rico, must consult your policy or certificate of benefits for detailed information. You can identify the provider network in United States and you contact information on the back of your medical plan card. In case you have a separate card to access services in the United States, it will also information about your provider network in United States and their contact information.

The provider in the United States may be able to verify eligibility by contacting our Provider Services Call Center in Puerto Rico at 1.800.981.4766 (toll free).