If you are not satisfied with the care you are receiving, please call First Medical at 1-844-347-7800; TYY/TDD users should call 1-844-347-7805.
Tell them you need to file a complaint. You can also visit First Medical’s Service Offices. You can file a complaint at any time.
Your doctor, family member, or your representative can file a grievance for you if you authorize them to do so.
You also have the right to call the Patient Advocate’s Office to file a complaint. Their number is 1-800-981-0031. You can also file a complaint with ASES. Their number is 1-800-981-2737.
No one can harm you if you file a complaint.
First Medical has seventy-two (72) hours to resolve your complaint. If they cannot resolve your complaint quickly, it will become a “grievance”. In this case, First Medical has up to ninety (90) days to resolve it, but they must decide more quickly if it is important for your health. First Medical must inform you how the complaint was resolved.
If First Medical does not resolve your complaint, you can request an Administrative Law Hearing in which you can explain the matter to a judge.
If your doctors or First Medical have made a decision about your care with which you do not agree, you can file an appeal. When you appeal, you are asking First Medical to reevaluate the mistake you believe they made.
If First Medical denies, reduces, limits, suspends, or terminates your healthcare services, they will send you a letter by mail. The letter will contain information such as:
If you disagree with the decision, you can file an appeal.
You have sixty (60) days from the date of the letter to file an appeal.
Your doctor or authorized representative can file the appeal for you if you authorize them to do so.
There are many ways to file an appeal. You can:
First Medical Health Plan, Inc.
Department of Grievance and Appeals – FM Vital
PO Box 195079
San Juan, PR 00919-5079
Your appeal will be reviewed by a team of experts that have not been involved with the issue of your appeal. First Medical will make a decision within thirty (30) calendar days. If you have an emergency and First Medical 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 First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805, visiting any of First Medical Service Offices, or writing a letter to First Medical at:
First Medical Health Plan, Inc.
Department of Grievance and Appeals – FM Vital
PO Box 195079
San Juan, PR 00919-5079
If First Medical agrees to give you a fast appeal, they will decide your case within seventy-two (72) hours. If First Medical does not agree to give you a fast appeal, they will call you within two (2) business days to let you know they will decide your case within thirty (30) calendar days.
If First Medical can’t make a decision within thirty (30) calendar days, they can ask for up to fourteen (14) calendar days. If they ask for more time, they have to let you know why. If you do not agree to give First Medical more time, you can file a complaint.
Once First Medical makes a decision, they will send you a letter within two (2) business days. The letter will tell you what they decided and that you have the right to ask for a hearing if you do not agree with the decision.
If you are not satisfied with First Medical’s decision about a complaint or an appeal, you can ask for an Administrative Law Hearing. An Administrative Law Hearing is where you can tell an Official Examiner about the mistake you think First Medical made. You have one-hundred and twenty (120) calendar days from the date of First Medical’s decision to ask for an Administrative Law Hearing with ASES.
For more information or to request an Administrative Law Hearings:
Calling the Vital Plan Call Center at:
1-800-981-2737
Writing ASES at:
ASES
PO Box 195661
San Juan, PR 00919-5661
Sending a fax to ASES at:
(787) 474-3347
Before the Administrative Law Hearing, you and your representative can ask to look at the papers and records that First Medical will use. First Medical must give you access to those papers and records for free.
During the Administrative Law Hearing, you can give facts and proof about your health and medical care. An Official Examiner will listen to everyone’s side. At the Administrative Law 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 ninety (90) calendar days. If you need a fast decision, the Official Examiner will decide your case within seventy-two (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.
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:
If you keep getting services during your appeal or Administrative Law Hearing and you lose, you might have to pay First Medical back for the services you got during the appeal or Administrative Law Hearing process.
To continue getting services during your appeal or Administrative Law Hearing, call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805.
