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.

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 item or 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 to us at:

Bright Health Member Services: 844-202-4031 TTY: 711

  • Inpatient Fax: 888-972-5113
  • Outpatient Fax: 888-972-5114
  • Behavioral Health Fax: 888-972-5177

Mailing Address: 10008 N Dale Mabry Highway Tampa, FL 33618

If your provider is unsure whether an item or service is covered, he or she should request a pre-authorization to confirm payment of services. Your provider should not bill you for services that were not covered due to a failure to obtain an authorization

If you do not agree with the coverage decision that we have made, you have the right to appeal and/or complain through our appeals and grievances processes listed in the next sections.

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.

Medicare Part C reconsideration (appeal)

We understand that healthcare is personal and can be complicated. That’s why we’ve put together the following Q&A to take some stress out of the process. If at any time you have questions that we do not address here, call Member Services at 844-202-4031 TTY: 711 Monday–Friday, 8am–8pm local time.

Fax or mail an appeal form , along with any additional information that could support your reconsideration request, to Bright Health.

Fax Number: 1-800-894-7742

Mailing Address:

Bright Health Medicare Advantage – Appeals & Grievances
PO Box 853943
Richardson, TX 75085-3943

If you have received an unfavorable medical care decision, you can ask for a reconsideration (appeal) by following the instructions given in the determination. Reconsiderations can be requested on any pre-service adverse determination or any claim determination where you are financially liable for all or part of the claim and you think we did not process the claim correctly, or that you were not notified that we would not cover an item or service.

Reconsiderations are generally resolved within 30 calendar days for pre-service, or 60 calendar days for claim reconsiderations.

Bright Health is dedicated to resolving every reconsideration request quickly and accurately as possible. Many times, our answer will be faster than 30 or 60 days. If your request is pre-service and waiting could seriously jeopardize your life, a limb, or function of limb, an expedited reconsideration can be requested. A clinician will review your request to see if it qualifies under the federal guidelines for expedited handling, and we will notify you by phone within 24 hours of the status of your expedited request. If we agree that your situation qualifies, we will complete our review within 72 hours of your original request date/time. If we don’t agree that your situation qualifies, we will complete our review within the standard 30 days.

All appeal requests must be within 60 days of a notice of unfavorable medical care decision.

If we denied a request for service or we denied a request to pay for an item or service, you will receive a letter with the reason why we denied the request and your appeal rights. This letter from Bright Health starts the 60-day clock, not when you receive a bill from your provider.

When we process your claim, we will generate an "Explanation of Benefits" (EOB). When you receive an EOB and you do not agree with your cost-share, you have the right to appeal that decision within 60 days of the date listed on your EOB.

The right to appeal is for you and anyone you appoint to help you (including your healthcare provider). If you want to appoint someone, other than your provider, to help you file a reconsideration request, please refer to the How to Appoint a Representative section for additional information.

File your reconsideration within the 60 days and include a note telling us who has additional information to support your request. When we get your request, we will ask your healthcare provider for that information to ensure that our review is complete. Remember, your reconsideration will be approved more quickly if we have all the information needed to show your request meets Medicare coverage guidelines.

Your reconsideration will be reviewed by our dedicated appeals and grievances staff within the time limits listed above. Whether our decision is overturned or upheld, you will receive a copy of our decision in writing.

If you receive this letter, it means that we feel our original denial is correct. Whenever we continue to uphold a denial, we are required to automatically forward our reconsideration decision (along with necessary medical records, contracts, criteria, etc) to the Independent Review Entity (IRE) for confirmation of our review. The IRE works for Medicare (not Bright Health) and they will complete a review of our review. If they agree with us, you will receive a letter with that decision and your appeal rights. If they agree with you, we will reprocess your pre-service request or claim according to their decision.

You may request an aggregate report of Bright Health operations specific to appeals, grievances, and exceptions made by our plan. This report will contain no Protected Health Information (PHI) and will be of the last reporting period available. To request this report, please call the member services number on the back of your member ID card.

Medicare Part C Grievances

A grievance is any complaint, other than one that involves a plan denial of an organizational determination or an appeal. If you have a complaint about quality of care, waiting times, or the member services you receive, you or your representative should call Bright Health Member Services at 844-202-4031 TTY: 711 Monday–Friday, 8am–8pm local time.

We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, you can file a written grievance.

You can start the process for any grievance, including a grievance is about the care our provider delivered (known as a Quality of Care complaint), by calling Bright Health Member Services at 844-202-4031 TTY: 711 Monday–Friday, 8am–8pm local time.

You can also contact Medicare’s Quality Improvement Organization (QIO) 

Or you can write our Appeals & Grievances department at:

Bright Health Medicare Advantage – Appeals & Grievances PO Box 853943 Richardson, TX 75085-3943

Fax number: 1-800-894-7742

Grievances are generally resolved within 30 calendar days from the day we receive the grievance.

When an appeal is still open, you can grieve about the process for filing, the processing of, or the determination of that appeal. This type of grievance is classified as a "standard grievance."

If your grievance is about our refusal to handle your appeal under the expedited timeframe, or if you do not agree with our use of a review extension, your grievance is classified as a "fast grievance." We respond to fast grievances within 24 hours of receipt.

Bright Health is dedicated to resolving every grievance request as quickly and accurately as possible – and many times, our answer will be faster than 30 days.

If your grievance is about our refusal to handle your appeal under the expedited timeframe, or if you do not agree with our use of a review extension, your grievance is classified as a "fast grievance." We respond to fast grievances within 24 hours of receipt.

Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after the problem you want to grieve occurred.

You and anyone you appoint to help you may file a grievance on your behalf. If you want to appoint someone to help you file a written grievance, please refer to the How to Appoint a Representative section for additional information. Include your appointee information in your grievance letter.

If you have complaints or concerns about Bright Health Medicare Advantage plans and would like to contact Medicare directly, fill out and submit Medicare's Complaint Form .

You may request an aggregate report of Bright operations specific to appeals, grievances, and exceptions made by our plan. This report will contain no Protected Health Information (PHI) and will be of the last reporting period available. To request this report, please call the member services number on the back of your member ID card.

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Give us a call for some hands-on help. We're happy to answer questions and get you covered. 844-667-5502 (TTY: 711)

Last Updated: Tues Oct 1 2019

Y0127_Bright_Health

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 http://www.medicare.gov 

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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