Complaint to the Patient Advocate: health plan, hospital or provider

OPP defines a complaint as a claim brought by the patient or their authorised representative raising any violation of patient rights by insurers, mental health organisations or health service providers. That is: it covers your health plan, but also the hospital, the clinic, the physician and mental health organisations. Once filed, OPP describes that the complaint is referred to a complaints officer, that the information provided by both parties is evaluated, and that a determination is made as to whether your rights were violated.

The patient or their authorised representative may file. OPP does not publish additional eligibility requirements or a filing deadline on this page, so none is asserted here: if your situation is time-sensitive, ask on the call. If your case is a denial or a delay relating to hospitalisation or an emergency, there is a different and far faster procedure under Act 47-2017, with a 72-hour term, and that is the route you want.

• Being the patient or their authorised representative.Verified against the official source
• That a violation of patient rights by an insurer, a mental health organisation or a health service provider is raised.Verified against the official source
• If filing by email: completing the Investigation Request in the document, in the format provided.Verified against the official source

• The Investigation Request, which OPP publishes for download and completion, if you go the email route.
• OPP does not publish a mandatory evidence list on this page. Bringing the insurer’s written denial, the relevant medical records and the dates of what happened is sensible, but confirm on the call.

1. 1

   Step 1: First, rule out the urgent case

   If what is happening is that a hospitalisation, or something in an emergency, is being denied, reduced, terminated, unpaid or delayed, do not take this route: Act 47-2017 has a summary procedure that stays the insurer’s determination and requires OPP to resolve within no more than 72 hours. That has its own guide here and it is what to trigger the same day.

2. 2

   Step 2: Call the Guidance Centre

   OPP puts the call first: the Guidance and Information Centre for Patients and Families answers at (787) 977-0909, from 8:00 am to 4:30 pm. It also publishes 1-800-981-0031. There you get guidance and, per OPP itself, you can file by calling the Centre.

3. 3

   Step 3: Or visit the nearest office

   OPP states you may file the complaint, together with its request, by visiting the Office of the Patient Advocate nearest your home. The list of offices is on its portal.

4. 4

   Step 4: Or email the Investigation Request

   To bring a claim this way, OPP says to download the Investigation Request and complete it in the document, in the format provided. Once completed, it is emailed to info@opp.pr.gov. “In the format provided” is not decorative: filling the document in loosely is the commonest way to have it sent back.

5. 5

   Step 5: Know what happens next

   OPP describes the sequence: once filed, your complaint is referred to a complaints officer, the information provided by both parties is evaluated, and a determination is made as to whether your rights were violated. It does not publish how long that takes, so this guide gives no timeframe.

By phone to the Guidance and Information Centre for Patients and Families, (787) 977-0909, 8:00 am to 4:30 pm, or 1-800-981-0031; by visiting the Office of the Patient Advocate nearest your home, listed on opp.pr.gov; or by sending the completed Investigation Request to info@opp.pr.gov. OPP also publishes (787) 710-7057. Its address is Ave. Ponce de León, Mercantil Plaza Building, Hato Rey, P.R. 00917.

• Taking the ordinary route when the case involves hospitalisation or an emergency and the Act 47-2017 72-hour procedure applies.
• Believing OPP only handles complaints against health plans, when it also covers health service providers and mental health organisations.
• Not knowing you can file with a call to (787) 977-0909.
• Sending the Investigation Request without completing it in the format provided.
• Waiting to “see if it resolves itself” without having asked whether a deadline exists.
• Not keeping the insurer’s written denial or the dates of what happened.

These are the government pages this guide is based on.

• Oficina del Procurador del Paciente (OPP)

  Procurador del Paciente

  www.opp.pr.gov

• Office of the Patient Advocate — official site

  OPP

  www.opp.pr.gov

• OPP — offices

  OPP

  www.opp.pr.gov