Puerto Rico Provider Resources

Provider Manual

Our Provider Manual is intended to serve as a reference guide to assist you and your staff in understanding all required administrative procedures related to the services you provide to our contracted health plan's affiliated members.

Annual Trainings

Therapy Network requires, in accordance with state/federal regulations that compliance, FWA and HIPAA trainings be completed by contractors and subcontractors, as well as their employees, within 30 days of hire/contracting and annually thereafter. Records of the training must be maintained and readily available at the request of Therapy Networks's Compliance Officer, AHCA, CMS or agents of both agencies, upon request.

NOTE: For providers who function under more than one Tax ID; please be sure to complete an attestation for each Tax ID that is contracted with Therapy Network.

Affirmative Statement about UM Decision Making

All clinical staff that makes Utilization Management (UM) decisions is required to adhere to the following principles:

• UM decision making is based only on appropriateness of care and service and existence of coverage.
• The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
• Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
• Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support benefit denials.

Annual Quality Improvement Documents

Annually the Quality Improvement (QI) Department develops Quality documents, which includes a QI & UM Evaluation, Program Description, and Work Plan. The development of the Quality documents satisfies Health Plan and NCQA Accrediting body requirements. The QI & UM Evaluation analyze the QI department's previous year quality indicators, key accomplishments, identify any areas needing improvement, and develop action plans to improve results. The Program Description and Work Plan establish objectives, goals, QI activities, and the QI Program Structure for the current year.

Copies of the annual QI documents are available by contacting the QI department at the following address:

Members with LEP may not understand health information concerning their care:

• The organization will provide language assistance services to individuals with Limited English Proficiency (LEP), and facilitate effective communication for the patient.
• The organization will provide notice about the availability of language assistance services and auxiliary aids and services to patients at no extra cost. For individuals with disabilities and the Dual Eligible Special Needs Plans (D-SNPs) population who require auxiliary aids and services, these notices will be provided in alternative formats to ensure effective communication to patients at no extra cost.
• The notices will be provided annually, upon request.

Clinical Practice Guidelines

The organization uses local and national Medicare coverage guidelines, Health Plan partner Clinical Guidelines (depending on the LOB) for Medical necessity determinations or, if none applicable, will use Apollo and MCG Clinical Guidelines to support benefit determinations. These guidelines are based on appropriateness and medical necessity standards; each guideline is current and has references from the peer-reviewed medical literature, and other authoritative resources such as CMS Medicare. 

For any medical necessity Recommendation of Denial, the Medical Director shall attempt to contact the requesting provider for peer-to-peer consultation. Applied Clinical Guidelines are available in both electronic and hard copy format. If a provider would like a copy of the guidelines, they may contact their assigned Provider Relations Representative and a copy will be provided.

Evaluation-First Therapy Authorization Process

At TNPR we must guarantee that the practice of the therapy is performed in compliance with the standards of Medicare & Medicare Advantage healthplans. Therefore, in accordance with the Provider Manual (page 8, 1st paragraph), whenever a medical order is submitted for physical therapy, the provider must complete the evaluation and plan of treatment BEFORE sending the Intake Form to request an authorization number. It is not acceptable to do this in reverse.

It is important to stress that every provider must offer the necessary therapy to the patient. It is not an acceptable practice to discontinue necessary treatment, waiting for an authorization number.

Please keep in mind, a standard authorization can take up 72 hours to be processed and you will need to have all available documentation in the medical record of the patient, in case it is requested by TNPR.

Claims Contact Information

1 (877) 614-5056 Option 3

Authorizations Contact Information

Phone: 1-877-614-5056 Option 1

Provider Relations Representatives

If you have any questions or need assistance, please reach out to your Provider Relations Representative

• Ricardo Grover
  Network Director
  787-473-2819
  GroverR@healthnetworkone.com
• Rory Rivera
  Network Manager
  787-546-3863
  RiveraR@healthnetworkone.com
• Fredly Jimenez
  Provider Relations Representative
  787-983-1835
  JimenezF@healthnetworkone.com
• Marla Camareno
  Provider Relations Representative
  954-478-6404
  CamarenoM@healthnetworkone.com
• Yaritza Laboy
  Provider Relations Representative
  787-983-1864
  LaboyY@healthnetworkone.com

2024 Copays

Evaluation-First Therapy Authorization Process

At TNPR we must guarantee that the practice of the therapy is performed in compliance with the standards of Medicare & Medicare Advantage healthplans. Therefore, in accordance with the Provider Manual (page 8, 1st paragraph), whenever a medical order is submitted for physical therapy, the provider must complete the evaluation and plan of treatment BEFORE sending the Intake Form to request an authorization number. It is not acceptable to do this in reverse.

It is important to stress that every provider must offer the necessary therapy to the patient. It is not an acceptable practice to discontinue necessary treatment, waiting for an authorization number.

Please keep in mind, a standard authorization can take up 72 hours to be processed and you will need to have all available documentation in the medical record of the patient, in case it is requested by TNPR.