Appeals and Grievances

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Grievance filing process:

The complaint or grievance process is only use for certain type of problems. This includes problems related to healthcare quality, waiting time and the customer service you receive. Also it can be used to express general dissatisfaction about the benefit plan design, the established copayments and the service received in a pharmacy. The grievance must be submitted within the 60 days following the event or incident.

For example, a complaint you make about us or regarding our network providers or pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve Organization Determinations or a Part D Coverage determination or payment disputes.

Your written request should include: your name, address, member number, reasons for complaining and or any evidence you wish to attach with a brief description of the problem which motivates the complaint. Also, include the names of the people involved, incident date, documents copies and any other relevant information which can contribute to our investigation.

For detail information about appeals and grievances you can contact our Member Service Center or refer to Chapter 9, Section 5, 6 and 7 of your Evidence of Coverage. For Optimo and Basic refer to Chapter 7, Section 4, 5 and 9 of your Evidence of Coverage.

How to file a grievance with my plan?

  • You can call at 1-888-620-1919 Monday to Sunday, from 8:00am to 8:00pm. TTY/TDD users should call at 1-866-620-2520
  • You can send an email to appeals-grievances@sssadvantage.com
  • You can fax to 787-993-3261
  • You can send it by mail to:
Triple-S Advantage

Appeals and Grievances Department


PO Box 11320
San Juan, PR 00922

How to file a complaint with Medicare?

You can submit comments on your health plan or Medicare drug plan, your comments will help the Centers for Medicare and Medicaid continue to improve the quality of the Medicare program.
Medicare Complaint Form

Appeal filing process:

The initial determination we make is the starting point for dealing with requests you may have about covering a Part C medical care or service you need, or paying for a Part C medical care or service you already received. Initial decisions about Part C medical care or services are called “organization determinations”. With this decision, we explain whether we will provide the Part C medical care or service you are requesting, or pay for Part C medical care or service you already received.

If we make coverage decision and you are not satisfied with, you can appeal the decision. An appeal is the formal way of requesting us a review to change an initial determination of coverage or payment. We will review the coverage decision or payment taken and verify if the rule used to process the decision was adequate. Your appeal will be reviewed by a different reviewer. We will complete the review and will inform you about the determination.

For detail information about appeals and grievances you can contact our Member Service Center or refer to Chapter 9, Section 5, 6 and 7 of your Evidence of Coverage. For Optimo and Basic plan refer to Chapter 7, Section 4, 5 and 9 of your Evidence of Coverage.

How to file an appeal?

You can submit the information using any of the following methods:

  • You can call at 1-888-620-1919 Monday to Sunday, from 8:00am to 8:00pm to submit a verbal appeal, TTY/TDD users should call at 1-866-620-2520.
  • You can send an e-mail to appeals-grievances@sssadvantage.com
  • You can fax to 787-993-3261
  • You can send it by mail to:
Triple-S Advantage

Appeals and Grievances Department


PO Box 11320
San Juan, PR 00922

Appointment of representative

If you would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on your behalf, you or the person accepting the appointment must fill out this form (or a written equivalent) and submit request to our Customer Service Area.

  • You can call at 1-888-620-1919 Monday to Sunday, from 8:00am to 8:00pm. TTY/TDD users should call at 1-866-620-2520.
  • Triple-S Advantage

    Compliance Department/Appeals and Grievances Department


    PO Box 11320
    San Juan, PR 00922
    Appointment of Representative Form

    Part D drug appeal process:

    How to file a Part D drug appeal?

    If you disagree with our decision to deny a request for coverage, prescription drugs or payment for services or drugs you already received you may file an appeal to stop services that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item, or service you think you should be able to receive. You have 60 days to file a Part D drug appeal.

    If you are appealing a decision that we made about a Part D drug, you and/or your doctor should decide if you need a fast appeal. You, your doctor, or your representative can ask for a fast appeal.

    • For a fast decision about a Part D drug – we have 72 hours to decide, but will decide sooner if your health condition requires it. If we do not decide within 72 hours, your request will automatically go to appeal Level 2.
    • For a standard decision about a Part D drug – we have 7 days to decide, but will decide sooner if your health condition requires it. If we do not give you a decision within 7 days, your request will automatically go to appeal Level 2.

    For detail explanation of the Part D Appeal process, please refer to the Chapter 9, Section 7.5 of your Evidence of Coverage.

    • You can call at 1-888-620-1919 Monday to Sunday, from 8:00am to 8:00pm to submit a verbal appeal. TTY/TDD users should call at 1-866-620-2520.
    Request Form to File Part D Drug Appeal
    Triple-S Advantage

    Grievances & Appeals Department


    PO Box 11320
    San Juan, PR 00922

    How to obtain an aggregate number of grievances, appeals, and exceptions filed with Triple S Advantage?

    As a member of our plan, you have the right to get several kinds of information from us. This includes about the number of grievances and appeals made by members and the plan’s performance ratings, including how it has been rated by the plan members and how it compares with other Medicare Advantage health plans.

    If you want this information, you can contact the Customer Service Department Monday through Sunday from 8:00 a.m.to 8:00 pm at 1-888-620-1919. TTY/TDD users should call at 1-866-620-2520.

    Last update: 10/02/2016

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