Puerto Rico Medicaid — Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES)
| Program name | Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES) |
|---|---|
| Provider portal | https://www.ases.pr.gov |
| FFS claims payer ID | No single canonical ID — routing is fiscal-intermediary-specific. Verify per clearinghouse. |
| Medicaid timely filing | 90 days from date of service |
The federal ceiling for Medicaid timely filing is 12 months under 42 CFR §447.45; most states set a shorter window. Always verify the current policy on the Puerto Rico Medicaid provider portal before filing a late-billing appeal.
BCBS licensee in Puerto Rico
The Blue Cross Blue Shield Association licensee in Puerto Rico is Triple-S Salud. This licensee is not yet in the QuickIntell payer registry. See the full payer directory or the BCBSA national site for a provider-portal link.
Top commercial payers in Puerto Rico
The dominant commercial insurers operating in Puerto Rico, in approximate order of lives covered. Click through for per-payer claims payer IDs, timely filing windows, prior-authorization rules, and appeal procedures.
Medicaid MCOs in Puerto Rico
Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES) contracts with the following managed-care organizations to administer Medicaid benefits in Puerto Rico. MCO contracts dictate claims routing, prior-auth workflows, and appeal deadlines — route each claim by the member's MCO assignment, not the state FFS payer ID.
Medicare contractor and active LCDs in Puerto Rico
First Coast Service Options, Inc. is the Medicare A/B MAC for Puerto Rico: Part A and Part B fee-for-service claims from Puerto Rico go to it, and its Local Coverage Determinations decide local medical necessity. Durable medical equipment and supply claims go to CGS Administrators, LLC as the DME MAC. Home health and hospice claims are processed by Wellpoint Federal. In the current Medicare Coverage Database export, 137 active LCDs from these contractors apply to Puerto Rico claims.
- First Coast Service Options, Inc.
A/B MAC (Part A and Part B claims)
- CGS Administrators, LLC
DME MAC (durable medical equipment and supplies)
- Wellpoint Federal
Home health and hospice MAC
Selected active First Coast Service Options, Inc. policies for Puerto Rico
A selection, not the full list: policies with measured search demand come first, then those on topics that more contractors publish LCDs for.
- L36377 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities
- L34976 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
- L38805 Colon Capsule Endoscopy (CCE)
- L33252 Psychiatric Diagnostic Evaluation and Psychotherapy Services
- L37561 Cystatin C Measurement
- L33405 Polysomnography and Sleep Testing
- L33411 Surgical Management of Morbid Obesity
- L33583 Diagnostic and Therapeutic Esophagogastroduodenoscopy
- L33618 Major Joint Replacement (Hip and Knee)
- L33674 Duplex Scanning
- L33695 Non-invasive Extracranial Arterial Studies
- L33766 Visual Field Examination
Equipment, home health and hospice policies that apply in Puerto Rico
- L33822 Glucose Monitors
- L33789 Power Mobility Devices
- L33318 Knee Orthoses
- L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis
- L33718 Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
- L33792 Wheelchair Options/Accessories
- L33797 Oxygen and Oxygen Equipment
- L33393 Hospice - Determining Terminal Status
Steps to confirm which LCD governs a claim · Every active LCD by contractor
State-specific regulations affecting Puerto Rico billing
- 26 L.P.R.A. §101 et seq. (Puerto Rico Insurance Code)
- Ley Núm. 194 de 2011 (Puerto Rico Patient's Bill of Rights — Carta de Derechos del Paciente)
- Ley Núm. 122 de 1995 (Puerto Rico Health Insurance Code / HMO regulation)
Provider licensing & enrollment in Puerto Rico
Providers enroll via PRMMIS Provider Portal (prmmis.pr.gov). ASES contracts with Vital MCOs who credential separately; NPI required. Federal Medicare billing (Parts A/B/C/D) parallel for Medicare-eligible beneficiaries.
Major health systems headquartered in Puerto Rico
| Health system | Headquarters |
|---|---|
| HIMA•San Pablo Group | Caguas, PR |
| Hospital Auxilio Mutuo | San Juan, PR |
| Pavia Health (Grupo Pavia) | San Juan, PR |
| Hospital Metropolitano (Metro Pavia) | San Juan, PR |
| Centro Médico de Puerto Rico (Medical Center) | San Juan, PR |
Frequently asked questions — Puerto Rico billing
What is the Puerto Rico Medicaid program called?
Puerto Rico's Medicaid program is known as Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES). Providers enroll and manage claims through the provider portal at https://www.ases.pr.gov.
What is the Puerto Rico Medicaid timely filing limit?
Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES) requires initial claims to be filed within 90 days from the date of service. The federal ceiling is 12 months under 42 CFR §447.45; Puerto Rico's 90-day window is set by the state provider manual. Late-billing exceptions may be allowed with good-cause documentation — verify on the state portal before filing an appeal.
Does Puerto Rico Medicaid publish a single claims payer ID?
No single canonical claims payer ID is published for Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES). Claims route through the state's fiscal intermediary; look up the correct submitter ID in your clearinghouse directory (Availity, Change Healthcare/Optum, Waystar) and route managed-care claims by the member's MCO assignment.
Who are the largest commercial insurers in Puerto Rico?
The dominant commercial payers in Puerto Rico include Humana, UnitedHealthcare, Molina Healthcare, along with the BCBS licensee Triple-S Salud. Each payer's claims routing, timely filing, and prior-auth rules differ — see the per-payer guides linked above.
What Medicaid managed-care organizations operate in Puerto Rico?
Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES) contracts with 1 Medicaid MCO tracked in the QuickIntell registry, including Molina Healthcare. MCO contracts determine claims routing and appeal deadlines — route each claim by the member's MCO assignment, not by the FFS payer ID.
What state-specific billing regulations apply in Puerto Rico?
Puerto Rico has 3 tracked state-level statutes that affect medical billing and RCM: 26 L.P.R.A. §101 et seq. (Puerto Rico Insurance Code); Ley Núm. 194 de 2011 (Puerto Rico Patient's Bill of Rights — Carta de Derechos del Paciente); Ley Núm. 122 de 1995 (Puerto Rico Health Insurance Code / HMO regulation). These sit on top of federal protections such as the No Surprises Act, HIPAA, and 42 CFR §447.45.
Run cleaner claims in Puerto Rico with QuickIntell
QuickRCM, QuickAuth, and QuickERA are tuned to Plan de Salud del Gobierno / Vital (Puerto Rico Medicaid via ASES) and the commercial payers on this page — eligibility, prior auth, claim scrubbing, and ERA posting all run on real payer rules, not generic adapters.
Disclaimer
This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. State Medicaid policies, MCO contracts, and payer rules change without notice — always verify against the current provider manual from Puerto Rico Medicaid and the member ID card before submission.