P.R. Laws tit. 24, § 3050
All patients, consumers and users of medical and hospital health care services in Puerto Rico are entitled to:
(a) Be afforded simple, fair, and effective mechanisms or procedures to settle any differences with their health care plans, health care professionals, and medical and hospital facilities and services health care providers, as well as to be assured that said mechanisms and procedures include internal quality controls and external supervision to guarantee their reliability and efficiency.
(b) Be afforded internal mechanisms or procedures for appeals concerning said institutional health care plans or providers, including the timely written notice of any decision denying, limiting, or terminating the services, or refusing payment for services, as well as the grounds or basis for such denial, limitation, or termination, and the mechanisms and procedures available to appeal such decision.
(c) Prompt and timely settlement of all appeals filed by said consumers or users, including the speedy solution of those cases concerning urgent or emergency care, within the scope or standards required under Medicare.
(d) Have their claims reviewed by duly qualified and fully accredited health care professionals with training in the field pertaining to the treatment in question, who have not taken part in the initial decision of which a review is requested.
(e) Receive final written notice of the decision of which a review has been requested by the patient, consumer, or user, including the basis or grounds supporting said final decision and the external mechanisms or remedies available under the law to appeal said decision before [an] external entity.
(f) Simple, fair, and affordable mechanisms or procedures to settle any differences in matters such as waiting periods, operating hours, conduct of the personnel who handles the public, and the state and conditions of the facilities.
(g) Any external system of appeals provided by a health care plan or provider shall be available only in those cases in which consumers or users have exhausted all internal remedies. Said system shall be under the direction of duly qualified and fully accredited health professionals with training in the field pertaining to the treatment in question, who have not participated in the initial decision of which the review has been requested. Said system shall follow reviewing standards based on the proof presented and objective medical evidence. The system shall settle appeals in a fair, efficient and timely manner, which shall apply to any decision to deny, limit or terminate coverage or payment for services on the grounds that the treatment in question is on the experimental or research stage, or is not necessary from the medical standpoint and exceeds reasonable costs, or endangers the life or the health of the patient.
(h) Guardians shall acquire all the rights of patients-wards conferred by this section.
History —Aug. 25, 2000, No. 194, § 12; Dec. 16, 2009, No. 176, § 7.