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File a complaint with Medicare

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.

Medicare Complaint Form

Medical Services Reimbursement form

To submit a request for reimbursement (in paper), please fill out the Medical Services Reimbursement Form and send it along with the corresponding payment receipt to the address or fax number below.

Triple-S Advantage, Inc.
Claims Department
PO Box 11320
San Juan, Puerto Rico 00922
Fax: (787) 993-3261

Reimbursement Form

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.

Appointment of Representative

List of Out-of-Network Rules

HMO and Platino plans

With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), and out-of-area dialysis services.

You can obtain care from out-of-network providers when the providers of specialized services are not available in our network. Prior authorization is needed. You or your doctor must obtain the prior authorization. Contact Customer Services for more information on how to request prior authorization for services out-of-network.

For detailed information refer to your Evidence of Coverage or contact the plan.

PPO plans

As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out of network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.

  • You can get your care from an out-of-network provider; however, in most cases that provider must be eligible to participate in Medicare, except for emergency care. For services different than emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
  • You don’t need to get a referral or prior authorization when you get care from out-of-network provider.
  • If you are using an out-of-network provider for emergency care, urgently needed care, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.

Out-of-Network Pharmacy Coverage

You may go to any network pharmacy of your preference when filling a prescription. To find a pharmacy you can look in our Provider Directory, visit our website (www.ahmpr.com) or call Customer Services Department at 1-888-620- 1919 Monday to Sunday from 8:00 AM to 8:00 PM. TTY users should call 1-866-620- 2520

If you obtains your drug in out of network pharmacy you will paid the full cost of the prescription rather than paying just your coinsurance or copayment. You may ask us to reimburse you for our share of the cost by submitting a paper claim to us.

To submit a request for reimbursement (in paper), please fill out the Reimbursement Form and send it along with the corresponding payment receipt to the address or fax number below.

Please include the original pharmacy receipts with your request. Your request must include the following:

  • Name and contract number of the beneficiary who received the service.
  • Date of service
  • Stamp or letterhead of pharmacy’s name, address
  • Prescription number
  • Drug name
  • Dispensed quantity
  • Amount paid
  • Reason for requesting reimbursement
  • For services that require a precertification, include a copy of the precertification.
  • Daily dose
  • National Drug Code (NDC)
  • National Provider Identifier (NPI) of the physician and pharmacy

Triple-S Advantage

Departamento de Farmacia
PO Box 11320
San Juan, PR 00922
Fax: (787) 993-3262

Prescription Drug Reimbursement Form

Out-of-Area services through the Blue Card® program

Triple-S Advantage is an independent licensee of BlueCross BlueShield Association. This allows us to have relationships with other Blue Cross and Blue Shield Licensees (Host Blues) through the Medicare Advantage Program. When members access healthcare services outside the geographic area, the claim for those services will be processed through the Medicare Advantage Program and paid in accordance with the rules of the Medicare Advantage Program policies then in effect.

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.

For detailed information refer to your Evidence of Coverage or contact the plan.

Last update: 10/01/2016

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