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Welcome to the PMS Beneficiary personal page for the Vital Beneficiaries.

This is a secure and private webpage, which only you will have access to.

In this area you can see the following information:

  • Coverage Certification Letter
  • Medicaid Services History

You can save the documents or, if you like, print them.

IF IT IS YOUR FIRST TIME PRESS HERE TO REGISTER. You can create an USERNAME and a SAFE PASSWORD.

There are laws that protect your privacy. The Government of Puerto Rico, Plan de Salud Menonita (PSM), and your doctors can’t tell others certain facts about you. Read more about your privacy rights HERE.

You have the right to:

  • Be treated with respect and in a dignified way.
  • Get written information from your Insurer in English and Spanish and translated into any other language. You also have the right to get written information in an alternative format. Afterwards, you have the right to get all future written information in that same format or language, unless you tell your Insurer otherwise.
  • Get information about your Insurer, health care facilities, health care professionals, health services covered, and how to access services.
  • Choose a Primary Medical Group, your PCP, and other doctors and providers within your Preferred Provider Network.
  • Choose a dentist and a pharmacy among your Insurer’s network.
  • Contact your doctors when you want to and in private
  • Get medically necessary care that is right for you, when you need it. This includes getting emergency services, 24 hours a day, 7 days a week.
  • Be told in an easy-to-understand way about your care and all of the different kinds of treatment that could work for you, no matter what they cost or even if they aren’t covered.
  • Help to make decisions about your health care. You can turn down care.
  • Ask for a second opinion for a diagnosis or treatment plan.
  • Make an Advance Directive. Look at Part 6 of this guide for more information.
  • Get care without fear of physical restraint or seclusion used for bullying, discipline, convenience or revenge.
  • Ask for and get information about your medical records as the federal and state laws say. You can see your medical records, get copies of your medical records, and ask to correct your medical records if they are wrong.
  • File a complaint or an appeal about your Insurer or your care. Look at Part 6 of this guide for more information. The complaint can be filed in your Insurer’s office or in the Patience Advocate office.
  • Get services without being treated in a different way because of race, color, birthplace, language, sex, age, religion, or disability. You have a right to file a complaint if you think you have been treated unfairly. If you complain or appeal, you have the right to keep getting care without fear of bad treatment from your Insurer, providers, or Vital .
  • Choose an Authorized Representative to be involved in making decisions.
  • Provide informed consent.
  • Only have to pay the amounts for services listed in Part 4 of this guide. You can’t be charged more than those amounts.
  • Be free from harassment by your Insurer or its Network Providers with respect to contractual disputes between the Insurer and its Providers;
YOUR RIGHT TO PRIVACY (HIPAA)

Your health information is private. The law says that ASES and your Insurer must protect your information. ASES and your Insurer can share your information for your care, to pay your health claims, and to run the program. But we can’t share your information with others unless you tell us we can. If you want to know more about what information we have, how we can share it, or what to do if you don’t want your health information shared with certain people, call your Insurer.

ADVANCE DIRECTIVES

Advance Directives are your written wishes about what you want to happen, if you get too sick to be able to say. The written document that states your Advance Directives is called a living will. You can use either word: advance directive or living will.

Your doctor can give you information on how to make an Advance Directive. If you are in the hospital, the hospital staff can also give you information on Advance Directives. You can also call the Senior Citizens Advocate Office at 787-721-6121. They have free information about Advanced Directives.

A Durable Power of Attorney is a paper that lets you name another person to make medical decisions for you. This person can only make decisions if you are too sick to make your own. He or she can say your wishes for you if you can’t speak for yourself. Your illness can be temporary.

You do not have to fill out these papers for an Advance Directive or Durable Power of Attorney. It is your choice. You may want to talk to a lawyer or friend before you fill out these papers.

To make all of these papers legal, you need to have a lawyer watch you sign the form. Instead of a lawyer, you could also have your doctor plus two additional witnesses watch you sign the form. The two additional witnesses have to be of legal age and they can’t be related to you by blood or marriage.

Once the papers are signed by everyone, it is your rule about what you want to happen to you if you get too sick to be able to say. It stays like this unless you change your mind.

These papers will only be used if you get too sick to be able to say what you want to happen. As long as you can still think for yourself, you can decide about your health care yourself.

Give a copy of the papers to your PCP and to your family members so they know what you want to happen to you if you are too sick to say.

If you feel that your Insurer or your doctors aren’t complying with your wishes, or if you have any complaints, you have the right to call the Vital call center at 1-800-981-2737 or the Puerto Rico Patient Advocate Office at 1-800-981-0031. The phone call is free.

You have the responsibility to:

  • Understand the information in your guide and other papers that your Insurer sends you.
  • Give your doctor your health records and let them know about any changes in your health so that they can take care of you.
  • Follow your doctor’s instructions. If you can’t follow your doctor’s instructions, let them know.
  • Let your doctor know if you don’t understand something.
  • Help to make decisions about your health care.
  • Communicate your Advance Directive so your doctors know how you want to be treated if you are too sick to say so.
  • Treat your health care provider and your Insurer’s staff with respect and dignity.
  • Let PSM know if you have another insurance company that should pay your medical care.
  • Let ASES know if you find out about a case of fraud and abuse in Vital.

Appeal: A request from the enrollee for the review of a decision. It is a formal request made by the enrollee, his authorized representative or provider, acting on behalf of the enrollee with the consent of the enrollee, to reconsider a decision in the case that the provider does not agree.

Authorization: A written document through which a person freely and voluntarily authorizes another person or provider to represent, him/her for medical or treatment purposes or to initiate an action such as a grievance. It may also be used to end a previous authorization.

Benefits: The health care services covered under Vital.
CHIP: Children Health Insurance Program, a federal program that provides medical services to low-income children age 21 and under, through Insurers qualified to offer coverage under this program.

Commonwealth Population: Individuals, regardless of age, who meet State eligibility standards established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP.

Complaint: An expression of dissatisfaction about any issue that is not an Adverse Benefit Determination that is resolved at the point of contact.
Coordinated Care: Is the service provided to Enrollees by doctors who are part of the preferred network of providers in your Primary Medical Group. The PCP is the leading provider of services and is responsible to periodically evaluate your health and coordinate all medical services you need.

Copayment: Money you need to pay at the time of service.

Covered Services: Services and benefits included in Vital.

ELA Puro: An option available to public employees so they can maintain medical coverage when they lose eligibility in the Medicaid Program and the enrollment for other Insurers contracted under Law 95 has ended. This coverage is the same as the coverage of Vital.

Emergency Medical Condition: A medical problem so serious that you must seek care right away to avoid severe harm.

Emergency Services: Treatment of an emergency medical condition to keep it from getting worse.

Enrollee (Beneficiary): A person who after being certified as eligible under the Medicaid program has completed the enrollment process with the Insurer and for whom the Insurer has issued the ID Card that identifies the person as a Vital Beneficiary.

Enrollment Counselor: An individual or entity that performs choice counseling, or enrollment activities, or both.

Grievance: A formal claim made by the Enrollee in writing, by telephone or by visiting your Insurer or the Health Advocate Office, requesting a solution be granted when a service has been denied or allowed on a limited basis. A service; reduction, suspension or termination of a previously authorized service; total or partial denial of payment for a service; not having received services in a timely manner; when your Insurer has not acted on a situation according to the established terms, refusal of your Insurer to let the Enrollee exercise his/her right to receive services outside the network

HIPAA (Health Insurance Portability and Accountability Act): The law that includes regulations for establishing safe electronic health records that will protect the privacy of a person’s medical information and prevent the misuse of this information.

High Cost High Needs Program: A specialized program of coordinated care for Enrollees with specific conditions that require additional management due to the cost or elevated needs associated with the condition.

Hospital: A facility that provides medical-surgical services to patients.

Insurer: The company contracted with ASES to provide your medical services under Vital.

Medical Record: Detailed collection of data and information on the treatment and care the Patient receives from a health professional.

Medically Necessary: Services related to (i) the prevention, diagnosis, and Treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional capacity. Additionally, Medically Necessary services must be:

  • Appropriate and consistent with the diagnosis of the treating provider and not getting could adversely affect your medical condition;
  • Compatible with the standards of acceptable medical practice in the community;
  • Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;
  • Not provided solely for your convenience or the convenience of the Provider or Hospital; and
  • Not primarily custodial care (for example, foster care).

In order for a service to be Medically Necessary, there must be no other effective and more conservative or substantially less costly Treatment, service, or setting available.

Medicaid: Program that provides health insurance for people with low or no income and limited resources, according to federal regulations.

Primary Care Physician (PCP): A licensed medical doctor (MD) who is a provider and who, within the scope of practice and in accordance with Puerto Rico Certification and licensure requirements, is responsible for providing all required primary care to Enrollees. The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary. A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician.

Patient: Person receiving Treatment for his mental and physical health.

Prescription: Original written order issued by a duly licensed health professional, ordering the dispensing of a product, or formula.

Preferred Provider Network: Health professionals duly licensed to practice medicine in Puerto Rico contracted by your Insurer for the Enrollee to use as the first option. Enrollees can access these providers without Referral or co-payments if they belong to their Primary Medical Group.

Primary Medical Group: Health professionals grouped to contract with your Insurer to provide health services under a Coordinated Care model.
Prior-Authorization: Permission your Insurer grants in writing to you, at the request of the PCP, Specialist or sub-specialist, to obtain a specialized service.

Referral: Written authorization a PCP gives to an Enrollee to receive services from a Specialist, sub-specialist or facility outside the preferred network of the Primary Medical Group.

Specialist: A health professional licensed to practice medicine and surgery in Puerto Rico that provides specialized medical and complementary services to the primary physicians. This category includes: cardiologists, endocrinologists, neurologists, surgeons, radiologists, psychiatrists, ophthalmologists, nephrologists, urologists, physiatrists, orthopedists, and other physicians not included in the definition of PCP.

Second Opinion: Additional consultation the Enrollee makes to another physician with the same medical specialty to receive or confirm that the initially recommended medical procedure is the Treatment indicated for his condition.
Treatment: To provide, coordinate or manage health care and related services offered by health care providers.

Treatment: To provide, coordinate or manage health care and related services offered by health care providers.

If you are not happy with the care that you are getting, please call the PSM Beneficiary Service line 1-866-600-4753 (free of charge)/ 1-844-726-3345 TTY (hearing impaired).

Tell us that you need to make a complaint. You can also visit your any of the PSM Service Centers. You can make a complaint at any time.

Your doctor, a family member, or your representative can make a complaint for you if you authorize them to do so.

You also have the right to call the Patient Advocate Office to make a complaint. Their number is 1-800-981-0031. You can also make a complaint to ASES. Their number is 1-800-981-2737.

No one can do anything bad to you if you make a complaint.

Your Insurer has 72 hours to fix your complaint. If they can’t fix your complaint quickly, it will become a “grievance”. In this case, your Insurer has up to 90 days to fix it, but they have to decide faster if it’s important to your health. The Insurer must tell you how the complaint was fixed.

What happens if my complaint isn’t fixed?

If your Insurer does not fix your complaint, you can ask for a hearing. A hearing is where you can tell a judge about the issue.

What is an appeal?

If your doctors or your Insurer make a decision about your care that you don’t agree with, you can file an appeal. When you appeal, you’re asking your Insurer to take another look at a mistake you think was made.

If your Insurer denies, reduces, limits, suspends, or ends your health care services, they will send you a letter in the mail. The letter will have information like:

  • What decision your Insurer made
  • Why they made the decision
  • How to file an appeal

If you don’t agree with the decision, you can file an appeal. You have 60 days from the date of the letter to file an appeal. Your doctor or your representative can file the appeal for you if you authorize them to do so.

There are many ways to file an appeal. You can:

  • Call the PSM Beneficiary Service line 1-866-600-4753 (free of charge)/ 1-844-726-3345 TTY (hearing impaired)
  • Visit any of the PSM Service Centers
  • Mail your appeal at : PO Box 364128, San Juan, PR 00936

Grievance and appeals forms

Your appeal will be reviewed by a team of experts that have not been involved with the issue of your appeal. Insurer will make a decision within 30 days.

If you have an emergency and your Insurer agrees that you do, you can ask for an expedited or fast appeal. You, your doctor, or your representative can ask for a fast appeal by calling the PSM Beneficiary Service line at 1-866-600-4753 (free of charge)/ 1-844-726-3345 TTY (hearing impaired).  You can also visit any of the PSM Service Centers.

If your Insurer agrees to give you a fast appeal, they will decide your case within 72 hours. If your Insurer does not agree to give you a fast appeal, they will call you within 2 days to let you know they will decide your case within 30 days.

If your Insurer can’t make a decision within 30 days, they can ask for up to 14 more days. If they ask for more time, they have to let you know why. If you do not agree to give your Insurer more time, you can file a complaint.

Once your Insurer makes a decision, they will send you a letter within 2 business days. The letter will tell you the decision and that you have the right to ask for a hearing if you do not agree with the decision.

What can I do if I don’t agree with the decision?

If you are not happy with your Insurer’s decision about a complaint or an appeal, you can ask for a hearing. A hearing is where you can tell an Official Examiner about the mistake you think your Insurer made. You have 120 days from the date of your Insurer’s decision to ask for an Administrative Hearing with ASES.

You can get more information about hearings or request a hearing by:

  • Calling the Vital call center at: 1-800-981-2737
  • Writing ASES at: ASES PO Box 195661 San Juan, PR 00919-5661
  • Sending ASES a fax to: 787-474-3347

Before the hearing, you and your representative can ask to look at the papers and records that your Insurer will use. Your Insurer must give you access to those papers and records for free.

During the hearing, you can give facts and proof about your health and medical care. An Official Examiner will listen to everyone’s side. At the hearing, you can talk for yourself or you can bring someone else to talk for you like a friend or a lawyer.

The Official Examiner will decide your case within 90 days. If you need a fast decision, the Official Examiner will decide your case within 72 hours.

If you do not agree with the Official Examiner’s decision, you can file an appeal with the Court of Appeals of Puerto Rico. More information about how to file an appeal will be in the papers you get after the hearing.

Can I keep getting services during my appeal or hearing?

If you are already getting services, you may be able to keep getting services during your appeal or hearing. To keep getting services, all of these things must be true:

  • You file the appeal within 60 days of the date on the letter from your Insurer.
  • You ask to keep getting services by the date your care will stop or change or within 10 days of the date on the letter from your Insurer (whichever date is later).
  • You say in your appeal that you want to keep getting services during the appeal.
  • The appeal is for the kind and amount of care you’ve been getting that has been stopped or changed.
  • You have a doctor’s order for the services (if one is needed).
  • The services are something that Vital still covers.

If you keep getting services during your appeal or hearing and you lose, you might have to pay your Insurer back for the services you got during the appeal or hearing process.

To ask to keep getting services during your appeal or hearing, call the PSM Enrollee Service line 1-866-600-4753 (free of charge)/ 1-844-726-3345 TTY (Hearing impaired).

Unfortunately, there could be a time when you see fraud or abuse related to Vital. Some examples are:

  • A person lies about facts to get or keep Vital coverage
  • A doctor bills you or makes you pay cash for covered services
  • A person uses someone else’s ID card
  • A doctor bills for services that you did not get
  • A person sells or gives medications to someone else

If you find out about fraud or abuse, you must tell us about it. You can call your Insurer, the Patient’s Advocate Office or ASES. You do not need to tell us your name and we will keep your information private. You will not lose your Vital coverage if you report fraud or abuse.

If you want more information, you can visit the ASES website at www.asespr.org. On the website there is a form that you can use to make your report. Your Insurer’s website also has more information.

You can also help prevent fraud and abuse. Here are some things you can do:

  • Don’t give your ID Card to anyone else
  • Learn about your Vital benefits
  • Keep records of your doctor’s visits, laboratory tests and medications. Make sure you don’t get repeat services
  • Make sure your information is right on a form before you sign it
  • Request and review the quarterly summary of the services you receive. You may request the summary of services directly from your Insurer
PSM Beneficiary Service Line:
1-866-600-47531-844-726-3345 TTY
Provider Service Line:
1-855-297-0140

Plan de Salud Menonita © 2018. All rights reserved.