Organizational determinations, appeals, and grievances.

We have set up a process for coverage decisions, appeals and complaints. We want to be your first stop if you have a concern about your coverage or care.

Medicare Part C complaints (appeals & grievances)

Under your Bright Health Medicare Advantage plan, "appeals" and "grievances" are the two different types of complaints you can make.

  • An appeal is a formal process for asking us to review and change a coverage decision we have made. If we have made an unfavorable decision, you will be issued a letter explaining why we denied the request and how you can proceed with the appeals process. The first step in the appeals process is called Medicare Part C Reconsideration.

  • A grievance is a formal process for telling us about your dissatisfaction with any aspect of your healthcare plan, customer care, your provider, or treatment facility. Grievances do not include claims or service denials, as those are classified as appeals.

Coverage decision process

As you use your Bright Health Medicare Advantage plan, you have the right to ask us to cover items or services that you think should be covered. This is called an “organizational determination” or “coverage decision.” You can submit a pre-authorization request (sometimes known as a pre-service request) to us to start the process.

An organization determination is a decision that Bright Health makes to authorize payment for medical services that you or your healthcare provider have requested following a review of benefits, coverage, and applicable clinical data.

You may ask us to make a coverage decision before you receive certain medical services. You might submit a request, for example, if your provider is unsure whether we will cover a certain medical service or if your provider refuses to provide the care that you think you need.

You, your representative, or your provider can ask us for a coverage decision by calling, writing, or faxing your prior-authorization request.

Please enter your zip code at the top of the page so we can provide you with the most accurate process and contact information

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Last Updated: Tues Oct 1 2019


Bright Health plans are HMOs and PPOs with a Medicare contract. Bright Health’s New York D-SNP plan is an HMO with a Medicare contract and a Coordination of Benefits Agreement with New York State Department of Health. Our plans are issued through Bright Health Insurance Company or one of its affiliates. Bright Health Insurance Company is a Colorado Life and Health company that issues indemnity products, including EPOs offered through Medicare Advantage. An EPO is an exclusive provider organization plan that may be written on an HMO license in some states and on a Life and Health license in some states, including Colorado. Enrollment in our plans depends on contract renewal.

This information is not a complete description of benefits. Call 844-667-5502 | TTY:711 for more information.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

You must continue to pay your Medicare Part B premium.

Every year, Medicare evaluates plans based on a 5-star rating system.

Medicare beneficiaries may also enroll in Bright Health Medicare Advantage plans through the CMS Medicare Online Enrollment Center located at 

Bright Health Medicare Advantage plans are plans with a network of doctors, hospitals, pharmacies, and other providers. Out-of-network/noncontracted providers are under no obligation to treat Bright Health members, except in emergency situations.

Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

Other providers are available in our network. Most network providers participate through our Care Partner.

Bright Advantage Special Care (HMO SNP) has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through 2021 based on a review of Bright Advantage Special Care (HMO SNP) Model of Care.

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