Pre-authorization Program

The pre-authorization de MAPFRE LIFE is designed to help receive quality medical care in a cost-effective manner. It evaluates the need for quality medical care at the hospital level, ambulatory surgery, and special studies.

When your physician determines that you need a hospital admission or an ambulatory surgery or a study or special process, the highly specialized and trained medical personnel of MAPFRE LIFE shall validate the treatment plan and its medical needs and afterwards shall make recommendations based in four very important factors using the medical criteria established for scientific evidence and recognized in the medicine field.

• Medical need – the treatment proposed is the correct one for you or your dependent according to your diagnoses.
• Place of treatment – that the place of treatment is the appropriate and that you and our physician are offered the opportunity for treatment in a cost-effective environment and with the best service quality.
• The precise stay time – that the stay in a hospital is no longer or shorter than what is required for your medical condition. You and your dependents shall be hospitalized the necessary time that your condition requires according to the most recent medical guidelines.
• The appropriate treatment within the treatment plan proposed by the physician who requests the admission – your physician should offer the appropriate medical or surgical treatment for you diagnoses.

Do all persons insured by MAPFRE LIFE require a pre-certification?

No. Not all persons insured by MAPFRE LIFE are subjected to reviews for pre-certification. You shall identify your participation in the pre-authorization program according to your policy coverage.  Services shall be pre-certified according to the coverage negotiated in the plan and group. The process begins by placing a call to customer service.

Why do I need to be pre-authorized?

If your physician indicates that you or your dependent need an admission or ambulatory surgery or a study or especial process that is not covered it is necessary to follow these instructions:

CONTACT THE FOLLOWING PHONE NUMBERS:

787-250-5214
1-800-981-3271 (Puerto Rico)
1-866-616-4947 (USVI)

• Notifications for admissions or elective surgery shall be carried out at least 7 days before the admission or surgery.
• Based on the information provided, our case management personnel shall evaluate the course of treatment for the insured, the quality of care and shall approve or disallow the initial stay period for the patient.
• Within 24 hours from your pre-authorization, you and your physician, the hospital or ambulatory facility shall be notified, in writing.
• If you receive your authorization for a pre-authorization through the phone, make sure that you write down the pre-authorization number. It is very important to be able to receive the service.
• All the pre-authorizations are valid for 60 days. Any change shall require a new pre-authorization.
• The need for continuous stays at the hospital shall be reviewed by your doctor.

What if it is an emergency?

If you or your dependents are admitted to a hospital for emergency treatment, MAPFRE LIFE must be notified during the first 48 hours after the admission. An emergency admission can arise through the office of a physician or emergency room.

Is it necessary to pre-certify the treatment in the emergency room?

No. It is not necessary to pre-certify a treatment of the emergency room in a hospital unless the outcome is a hospitalization. In that case, the pre-certification for a preadmission must be obtained during the first 48 hours after the admission.

How can maternity be pre-certified?

For maternity admissions, MAPFRE LIFE must be notified within the first 48 hours of the admission to qualify to avoid or reduced the deductible, if applicable.  This is consistent with the manner in which the emergency cases are managed.

Is it necessary to pre-certify newborn admissions?

If a newborn cannot leave the hospital when the mother is released, the insured must call MAPFRE LIFE within 48 hours from the time of admission of the baby to provide the necessary information for evaluation.

What happens if I have to be hospitalized for a time longer than what was coordinated?

If the physician understands that there is a need to prolong your stay at the hospital, the Utilization Review Team shall coordinate the request for extension. MAPFRE LIFE shall discuss the situation with your physician and your extension or recommendation of alternatives that could turn out to be more suitable and of higher quality than a hospitalization.

What happens if the hospital admission is not approved?

If MAPFRE LIFE does not authorize the admission or surgical procedure, you and your physician shall be notified in writing (or by phone if the time is limited). You can choose to receive the treatment; however, an admission to the hospital without a pre-authorization number can be subject to limited benefits.

What happens if you do not use the program?

The pre-authorization program is an integral part of your health plan and you and your dependents should receive the proper and high quality care while at the same time reducing unnecessary costs. At the same time, it helps you receive the highest benefits available under your plan.

If you do not use this program or if MAPFRE LIFE is not notified of an admission, an ambulatory surgery, a study, or of a special procedure:

• Your benefits can be substantially reduced and subject to additional expenses.
• You will not know if the expenses that you incurred will be authorized by MAPFRE LIFE and covered by your policy.

When can a pre-authorization be rejected?

The pre-authorization can be denied if there is no medical need or if it is not part of the coverage.

Can I appeal?

If at any time MAPFRE LIFE does not authorize a treatment, you can appeal the decision in writing within 30 days, after the denial date.

Your physician can provide additional information to support your appeal. The Case Management personnel shall evaluate the new information and shall indicate the decision to your physician. This shall be explained in the denial letter.

Is the payment of health benefits guaranteed by the pre-authorization?

No. The pre-authorization helps you and your plan understand the treatment period and the stay but it does not guarantee the payment of benefits. Each claim can be subject to the medical policy according to the exclusions and limitations contained in the Master Policy. The provisions specified in your health plan shall determine the benefit covered.