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Part C - Medical Care and Services

Organizational Determinations

If you have problems getting the Part C medical care or services you need, or payment for a Part C service you already received, you must request an initial determination with the plan.

 

 

Initial Determinations

 

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 Part C "organization determinations." With this decision, we explain whether we will provide the Part C medical care or service you are requesting, or pay for the Part C medical care or service you already received.

 

 

  • You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your “appointed representative.” You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other people may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.

  • A decision about whether we will give you, or pay for, the Part C medical care or service you are requesting can be a “standard" decision” that is made within the standard time frame, or it can be a “fast" decision that is made more quickly. A fast decision is also called an “expedited" decision.

  • To ask for a standard decision for a Part C medical care or service you, your doctor, or your appointed representative should mail or fax a written request:

    Medicare y Mucho Más
    Member Services

    PO BOX 71114
    SAN JUAN PR 00936-8014
    Fax: 787-622-0485

     

    PMC
    Member Services

    PO Box 366292
    San Juan PR 00936-6292
    Fax: 787-999-9503

     

    First+Plus
    Member Services

    PO BOX 71114
    SAN JUAN PR 00936-8014
    Fax: 787-622-0485

  • You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.)

     

    If you are requesting a Part C medical care or service that you have not yet received, you, your doctor, or your representative may ask us to give you a fast decision by calling Member Services:

    MMM
    Member Services:

    787-620-2397 (Metro Area)
    1-866-333-5470 (Toll Free)
    1-866-333-5469 TTY (Hearing Impaired)

     

    PMC
    Member Services:

    787-625-2126 (Metro Area)
    1-866-516-7700 (Toll Free)
    1-866-516-7701 TTY (Hearing Impaired)

     

    First+Plus
    Member Services:

    787-522-7800 (Metro Area)
    1-888-767-7717 (Toll Free)
    1-877-672-4242 TTY (Hearing Impaired)

     

    Monday through Sunday, from 8:00 a.m. to 8:00 p.m.

     

     

    You can also send your request by mail or fax:

    Medicare y Mucho Más
    Member Services

    PO BOX 71114
    SAN JUAN PR 00936-8014
    Fax: 787-622-0485

     

    PMC
    Member Services

    PO Box 366292
    San Juan PR 00936-6292
    Fax: 787-999-9503

     

    First+Plus
    Member Services

    PO BOX 71114
    SAN JUAN PR 00936-8014
    Fax: 787-622-0485

     

     

    Be sure to ask for a “fast or “expedited” review. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

     

    If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance.” You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review (for more information about fast grievances, see your plan’s Evidence of Coverage). If we deny your request for an expedited initial determination, we will give you a standard decision.

  • For a decision about payment for Part C medical care or services you already received:

    If we do not need more information to make a decision, we have up to 30 days to make a decision after we receive your request, although a small number of decisions may take longer. However, if we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make a decision. You will be told in writing when we make a decision.

     

    If you have not received an answer from us within 60 days of your request, you have the right to appeal.

     

    For a standard decision about Part C medical care or services you have not yet received:

    We have 14 days to make a decision after we receive your request. However, we can take up to 14 more days if you ask for additional time, or if we need more information (such as medical records) that may benefit you. If we take additional days, we will notify you in writing. If you believe that we should not take additional days, you can make a specific type of complaint called a “fast grievance”.

     

    If you have not received an answer from us within 14 days of your request (or by the end of any extended time period), you have the right to appeal.

     

    For a fast decision about Part C medical care or services you have not yet received.

    If you receive a “fast” decision, we will give you our decision about your requested medical care or services within 72 hours after we receive the request.  However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need more time to prepare for this review. If we take additional days, we will notify you in writing.  If you believe that we should not take any extra days, you can file a fast grievance.  We will call you as soon as we make the decision.

     

    If we do not tell you about our decision within 72 hours (or by the end of any extended time period), you have the right to appeal. If we deny your request for a fast decision, you may file a "fast grievance."

  • For a decision about payment for Part C medical care or services you already received.

    Generally, we must send payment no later than 30 days after we receive your request, although a small number of decisions may take up to 60 days. If we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make payment.

     

    For a standard decision about Part C medical care or services you have not yet received.

    We must authorize or provide your requested care within 14 days of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

     

    For a fast decision about Part C medical care or services you have not yet received.

    We must authorize or provide your requested care within 72 hours of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

  • If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision.

Out-of-Network Coverage

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.

 

For detailed information refer to your plan’s Evidence of Coverage or contact Member Services.

 

Quality Improvement Program

By implementing the Quality Improvement Program (QIP). MMM Healthcare, LLC will assure that the provision of healthcare services to its Medicare members are: accessible, cost effective and of high quality. The scope of this QIP applies to all Medicare y Mucho Más (MMM), PMC Medicare Choice (PMC) and First+Plus products, including HMO and PPO plans with Medicare Advantage Prescription Drug (MA-PD) and Special Needs Plans (SNPs).

 

 

  • Our QIP contains detailed information of all the Quality Improvement Activities (QIAs) that we will conduct during the year to fulfill the Centers for Medicare and Medicaid Services (CMS) regulatory requirements, as well as for those of the National Committee for Quality Assurance (NCQA). All the activities conducted by MMM Healthcare, LLC and its administrative leadership are driven by the adoption of the definition of Quality in Healthcare of the Institute of Medicine:


    "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

  • The goal of the QIP is to achieve demonstrable improvement in member’s health, functional status and satisfaction across the broad spectrum of care and services provided. To obtain this goal, the organization will work to improve their processes to ensure desired healthcare outcomes for the benefit of its membership. 

    While the overall objectives are:

    • Develop quality initiatives based on the demographics and individual needs of the members ensuring that such initiatives support, culturally and linguistically, our diverse membership.

    • Develop a network of qualified providers - practitioners, facilities and other ancillary medical services - through a process of initial credentialing and re-credentialing every three years.

    • Promote appropriate preventive healthcare and wellness activities to improve the health status of members with serious and complex medical conditions by offering services to assist in managing their condition in collaboration with their primary healthcare team.

    • Analyze the data gathered, identify barriers that are related to the clinical practice and/or administrative aspects of the delivery system and implement interventions to improve those barriers that are relevant to our membership.

    • Ensure continuity and coordination of care, either medical or behavioral health care, between Primary Care Physicians (PCPs) and other practitioners during the transition from one level of care to another.

    • Monitor member and practitioner satisfaction to identify potential concerns and opportunities for improvement, and announce results to the organization’s leadership and stakeholders.

    • Actively demonstrate a commitment to patient safety by identifying and acting upon opportunities to improve the clinical practices of our network of providers.

    • Identify and investigate any potential quality of care issues that may adversely affect the healthcare services provided to our membership.

    • Have access to the medical records of our members to ensure that the documentation is appropriate and to assess if medically necessary services are being provided.

    • Maintain the confidentiality of data relating to individual members and practitioners.

    • Monitor the quality of care and services delivered by delegated entities with respect to standards established by the organization, regulatory agencies and stakeholders.

  • The Board of Directors (BOD) has the ultimate accountability for the quality of the care and the quality of the services provided to members. The BOD delegates its authority and responsibility for the Quality Improvement Program (QIP) to the Quality Improvement Committee (QIC) and has established that the Chief Medical Officer (CMO) is responsible for the overall oversight of it.


    Our 2016 QIP was reviewed and approved by Dr. Diego Rosso, Chief Medical Director, on March 14, 2016 and by Dr. Rick Shinto, Chief Executive Officer and Chairman of the BOD on March 18, 2016.

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