Puerto Rico's Código de Seguros de Salud (Ley Núm. 194 of 2011, as amended) sets out requirements for health insurance organizations in chapters, including credentials verification, quality, grievances, utilization review, provider networks and independent external review. This page is for organizations that need to compare their processes with those chapters. Integral Healthcare Solutions (IHS) runs a process-led gap assessment against the chapters and drafts the program documents for your team to approve.
Last reviewed: 2 October 2026
Compliance engagements are overseen by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC.
What is the Código de Seguros de Salud de Puerto Rico?
It is the health insurance code created by Ley Núm. 194 of 29 August 2011. The compilation we reviewed opens with the purpose “Para crear el Código de Seguros de Salud de Puerto Rico” and carries its amendments forward to Ley Núm. 161 of 2 August 2026. Source: Oficina de Gestión y Presupuesto (OGP) Biblioteca Virtual compilation.
Which chapters does this page cover?
Six chapters. Spanish titles are quoted exactly from the compilation. The English glosses are IHS's translation.
| Chapter | Title in the compilation (Spanish) | English gloss (IHS's translation) |
|---|---|---|
| 18 | Verificación de Credenciales de los Profesionales o Entidades de la Salud | Verification of Credentials of Health Professionals or Entities |
| 20 | Evaluación y Mejora de Calidad en las Organizaciones de Seguros de Salud o Aseguradores | Quality Evaluation and Improvement in Health Insurance Organizations or Insurers |
| 22 | Procedimientos Internos de Querellas de las Organizaciones de Seguros de Salud o Aseguradores | Internal Grievance Procedures of Health Insurance Organizations or Insurers |
| 24 | Revisión de Utilización y Determinación de Beneficios | Utilization Review and Benefit Determination |
| 26 | Suficiencia de las Redes de Proveedores para Planes de Cuidado Coordinado | Sufficiency of Provider Networks for Coordinated Care Plans |
| 28 | Revisión Externa Independiente | Independent External Review |
What does each chapter say it is for?
Each chapter has a statement of purpose. We quote one short phrase from each exactly as it appears, with IHS's translation. We quote nothing else from the chapters.
Capítulo 18. Verificación de Credenciales de los Profesionales o Entidades de la Salud
IHS translation: Chapter 18, Verification of Credentials of Health Professionals or Entities. The chapter's statement of purpose (Artículo 18.020) includes this wording: “establezcan un programa abarcador para verificar las credenciales de los profesionales o entidades de la salud”. IHS translation: “set up a comprehensive program to verify the credentials of health professionals or entities.”
Capítulo 20. Evaluación y Mejora de Calidad en las Organizaciones de Seguros de Salud o Aseguradores
IHS translation: Chapter 20, Quality Evaluation and Improvement in Health Insurance Organizations or Insurers. The chapter's statement of purpose (Artículo 20.020) includes this wording: “evalúen, mantengan y mejoren la calidad de los servicios de cuidado de la salud”. IHS translation: “evaluate, maintain and improve the quality of health care services.”
Capítulo 22. Procedimientos Internos de Querellas de las Organizaciones de Seguros de Salud o Aseguradores
IHS translation: Chapter 22, Internal Grievance Procedures of Health Insurance Organizations or Insurers. The chapter's statement of purpose (Artículo 22.020) includes this wording: “una oportuna y adecuada resolución de querellas”. IHS translation: “a timely and adequate resolution of grievances.”
Capítulo 24. Revisión de Utilización y Determinación de Beneficios
IHS translation: Chapter 24, Utilization Review and Benefit Determination. The chapter's statement of purpose (Artículo 24.020) includes this wording: “la continua evaluación y administración de los servicios de cuidado de la salud”. IHS translation: “the continuous evaluation and management of health care services.”
Capítulo 26. Suficiencia de las Redes de Proveedores para Planes de Cuidado Coordinado
IHS translation: Chapter 26, Sufficiency of Provider Networks for Coordinated Care Plans. The chapter's statement of purpose (Artículo 26.020) includes this wording: “sean adecuados, accesibles y de calidad”. IHS translation: “are adequate, accessible and of quality.”
Capítulo 28. Revisión Externa Independiente
IHS translation: Chapter 28, Independent External Review. The chapter's statement of purpose (Artículo 28.020) includes this wording: “una revisión independiente de las determinaciones adversas o determinaciones adversas finales”. IHS translation: “an independent review of adverse determinations or final adverse determinations.”
Which copy of the Code are these quotes from?
Chapter titles and the phrases above are taken from the OGP Biblioteca Virtual compilation of Ley 194-2011, as amended, marked “Rev. 21 de agosto de 2026” (amendments through Ley Núm. 161 of 2 August 2026), retrieved 2 October 2026 from bvirtualogp.pr.gov. It is a government compilation, not the enacted text as published by the Legislature or the official annotated laws. OGP directs readers to the original act and to its latest revised copy. Verify against the current official text before relying on it. The Oficina del Comisionado de Seguros also publishes a compilation of the Code whose cover note says it is not the official version and which lists amendments only through Ley Núm. 90 of 15 July 2014. This is general information, not legal advice.
Who needs to look at these chapters, and what brings it up?
The purpose articles we read address “organizaciones de seguros de salud o aseguradores” (IHS translation: health insurance organizations or insurers). Which events bring an organization to these chapters depends on its role, and this page lists no statutory triggers. IHS's reading, dated 2 October 2026: an organization that is not an insurer may meet these topics through a contract with one. That is IHS's reading, not a statement of what the Code requires of any organization. Whether and how the Code reaches you is a question for your lawyer.
How IHS helps
IHS markets a process. It does not offer an opinion on what the law means for you.
- Gap assessment. IHS compares your written processes and evidence against the chapter topics and against the text your counsel identifies as applicable, one chapter at a time, and records what is present, what is missing and where documents disagree with each other.
- Document and evidence mapping. Each process is tied to the document and the record that show it working.
- Program build. Where a process or document is missing, IHS drafts the policy, procedure and workflow for your clinicians and compliance staff to review and approve.
- Internal review. IHS reads the finished set as a reviewer on your team would, and lists what remains open for your team and counsel to decide.
Your organization supplies its current documents, its plan and contract inventory, access to the staff who run each function, and its lawyer's reading of how the Code applies. The real limit: IHS is a consulting firm, not a law firm. It does not decide which provisions bind you, and it does not predict how any authority will read your documents. IHS does not file anything with, or correspond with, any regulator on your behalf. Your named contact does that.
See also IHS compliance services, healthcare program development and credentialing program design.
What to have ready
- Credentialing. Your credentialing policy, the files you keep on professionals and entities, and the revalidation record. Chapter 18 is titled Verificación de Credenciales de los Profesionales o Entidades de la Salud.
- Quality. Your quality program description, work plan and committee minutes. Chapter 20 is titled Evaluación y Mejora de Calidad en las Organizaciones de Seguros de Salud o Aseguradores.
- Grievances. Your internal grievance procedure, the log of grievances received, and the letters sent in response. Chapter 22 is titled Procedimientos Internos de Querellas de las Organizaciones de Seguros de Salud o Aseguradores.
- Utilization review. Your utilization review procedures, criteria sources, and sample determination letters. Chapter 24 is titled Revisión de Utilización y Determinación de Beneficios.
- Networks. Your provider contract templates, network listings and any access analysis. Chapter 26 is titled Suficiencia de las Redes de Proveedores para Planes de Cuidado Coordinado.
- External review. The steps your adverse-determination letters describe for an independent review, and who owns each step. Chapter 28 is titled Revisión Externa Independiente.
- Plan inventory. A list of the plan types and lines of business you operate, so the work starts from the products that are in scope.
- Contracts. Any agreement with an insurer or health insurance organization that assigns one of these functions to you, and your organization chart for who owns each function.
- Counsel. The name of the lawyer who will decide how the Code applies to you. IHS does not give legal opinions.
- Current text. A copy of the current Code with its revision date, so the team works from one version.
When this list is in hand, the free discovery session is where we confirm scope.
How does this compare with accreditation standards?
A statute and an accreditation standard are different sources. The Code is a law with chapters; an accreditation standard is a body's published criteria for its own review. An organization may be subject to both. This page names no accreditor and does not suggest which, if any, to pursue.
What does it cost?
This page quotes no regulator fees. IHS scopes each engagement after a free discovery session.
What this is not
- It is not legal advice. IHS is a consulting firm, not a law firm.
- It is not a statement of what any authority requires of you. Check every statement here against the current official text of the Code before relying on it, and ask your lawyer how the Code applies to your organization.
- It is not a guarantee of any regulator's or reviewer's decision.
- It is not a Spanish-language page. Spanish appears only where it is the source text.
Frequently asked questions
What is the Código de Seguros de Salud de Puerto Rico?
It is Ley Núm. 194 of 29 August 2011, as amended. The compilation we reviewed states its first purpose as “Para crear el Código de Seguros de Salud de Puerto Rico.” It is organized in chapters; this page covers six of them, 18, 20, 22, 24, 26 and 28.
Which chapters does this page cover?
Chapter 18 (credentials verification), 20 (quality evaluation and improvement), 22 (internal grievance procedures), 24 (utilization review and benefit determination), 26 (provider network sufficiency for coordinated care plans) and 28 (independent external review). The Spanish titles in the table are quoted from the compilation; the English glosses are IHS's translation.
Is the Spanish title or the English gloss the one that counts?
The Spanish title is the source text. The English gloss is IHS's translation for readers and has no legal standing.
Does the Code apply to my organization?
That depends on what your organization is and what it does. The purpose articles we read speak to “organizaciones de seguros de salud o aseguradores,” that is, health insurance organizations or insurers. Whether a delegate, vendor or provider group is reached, directly or through a contract, is a question for your lawyer.
How current is the text quoted here?
The compilation is marked “Rev. 21 de agosto de 2026” and lists amendments through Ley Núm. 161 of 2 August 2026. We retrieved it on 2 October 2026. The Code can be amended after that date, so check the revision date on the day you rely on it.
Can IHS tell me whether I comply?
No. IHS is a consulting firm, not a law firm, and does not give legal opinions. IHS compares your written processes and evidence against the chapter topics and the text you and your counsel identify as applicable, shows where documents are missing or inconsistent, and drafts what is needed for your team to approve.
Does IHS file anything or correspond with a regulator for me?
No. IHS drafts the documents. Your organization's named contact makes any filing and handles any correspondence.
What does the work cost?
This page quotes no regulator fees. IHS scopes each engagement after a free discovery session, because the number of chapters, plan types and sites changes the work.
Does this page recommend an accreditor?
No. The Code and an accreditation standard are separate sources of requirements. Which accreditation, if any, suits your organization is your decision.