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.
View accurate process and contact information .
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Website Last Updated: Jan 13 2021