The plan will not authorise hospitalisation: the 72-hour procedure

It is the summary adjudicative procedure OPP implemented by regulation under Act No. 47-2017. It applies to denials of authorisation, adverse determinations or denials of health services relating to hospitalisation, the prolongation of hospitalisation or its unjustified delay, and to a patient’s emergency matters. The regulation defines an adverse determination broadly: it includes the insurer’s decision, directly or through a utilisation review organisation, denying, modifying the medical determination, delaying authorisation, reducing or terminating a hospitalisation service, or not paying for it in whole or in part, where the service was recommended or justified by a physician duly licensed in Puerto Rico. It also includes decisions based on the person’s eligibility to participate in the plan.

The regulation establishes that the complaint may be brought by the patient, a family member, the legal guardian, or any other person recognised by law to bring the claim under subsection (o) of Article 7 of Act No. 77-2013. That is, the patient need not be the one calling, which matters when the person is hospitalised or not in a condition to. The case must fall within the scope: hospitalisation, prolongation of hospitalisation, unjustified delay of it, or emergency matters.

• That the case is a denial of authorisation, adverse determination or denial relating to hospitalisation, prolongation of hospitalisation, unjustified delay of it, or a patient emergency matter.Verified against the official source
• That the filing is by the patient, a family member, the legal guardian, or any other person recognised by law to bring the claim.Verified against the official source
• Delivering all necessary documentation: the complaint is not deemed presented until every requested document is received.Verified against the official source

• The patient’s complete information.
• The justification of medical necessity.
• The insurer’s denial. The regulation describes that the adverse determination notice must contain the explanation of why, the patient’s name, the date of service, the diagnosis underlying the hospital admission and the proposed treatment, the diagnosis at the time of filing, the physician’s name, specialty, Puerto Rico medical licence number, and the specific clinical reasons for the denial.
• Any other document the Office requires. The patient’s medical record must be made available to the Patient Advocate if necessary.

1. 1

   Step 1: Recognise that this counts as an adverse determination

   You do not need a letter saying “denied”. The regulation includes modification of the medical determination, delay of the authorisation, reduction, termination, and non-payment in whole or in part. And it is explicit about delay: when the insurer delays authorising a hospitalisation medical order for more than twenty-four hours from when it was submitted, that is an adverse determination. If you have been waiting more than a day for “the authorisation”, you already have a case.

2. 2

   Step 2: Call OPP the same day

   The Guidance and Information Centre for Patients and Families answers at (787) 977-0909, from 8:00 am to 4:30 pm, and OPP also publishes 1-800-981-0031. Do not wait to “see if the plan changes its mind”: the value of this procedure is in the hours.

3. 3

   Step 3: Send EVERYTHING together, not in pieces

   This is where time is lost. The regulation says the complaint will be deemed presented when all necessary documentation is received by the OPP official and the acknowledgment of the email or fax is sent — and that it will not be deemed presented until every requested document is received. Necessary documentation includes the patient’s complete information, the justification of medical necessity and the insurer’s denial, among others. While one is missing, the 72-hour clock has not started.

4. 4

   Step 4: Answer fast if something is requested

   The regulation requires OPP to notify you in writing, within twenty-four hours of receiving the complaint, of any document or information needed to handle, evaluate and adjudicate it. That notice is the sign that the clock is still not running: get it and return it the same day.

5. 5

   Step 5: The insurer has five hours

   Once the complaint is complete, the Patient Advocate sends a copy of it and all documentation to the insurer or health services organisation involved, which has no more than five hours from notification to state its position. The regulation says that term is one of lapse: if it passes without an answer, the complaint’s allegations will be deemed correct and accepted by the insurer.

6. 6

   Step 6: Meanwhile, the decision is stayed

   It is the most reassuring part and the one fewest people know: the regulation establishes that the determination in question will be stayed until the Patient Advocate summarily adjudicates the complaint, within no more than seventy-two hours, to avoid harm to the patient.

Before the Office of the Patient Advocate. Guidance and Information Centre for Patients and Families: (787) 977-0909, 8:00 am to 4:30 pm; also 1-800-981-0031 and (787) 710-7057. OPP receives the completed Investigation Request at info@opp.pr.gov, and the regulation contemplates filing by email or fax with acknowledgment of receipt. Address: Ave. Ponce de León, Mercantil Plaza Building, Hato Rey, P.R. 00917. You may also visit the office nearest your home.

• Waiting for a denial letter when a delay of more than 24 hours already counts as an adverse determination.
• Sending the complaint incomplete: the 72-hour term does not start until OPP has every document and sends the acknowledgment.
• Ignoring the notice OPP sends within 24 hours asking for what is missing.
• Using the ordinary complaint in a hospitalisation case, losing the summary procedure.
• Believing only the patient can file, when the regulation admits a family member or the legal guardian.
• Not keeping the insurer’s written denial with the diagnosis and clinical reasons.

These are the government pages this guide is based on.

• Oficina del Procurador del Paciente (OPP)

  Procurador del Paciente

  www.opp.pr.gov

• Regulation for the summary adjudicative procedure, Act No. 47-2017 (docs.pr.gov)

  OPP

  docs.pr.gov

• Office of the Patient Advocate — official site

  OPP

  www.opp.pr.gov