This section describes how you can exercise your right to request a Coverage Determination under your Bright Health Medicare Advantage plan. A coverage determination is any decision made by the Part D plan sponsor regarding;
We hope that this Q&A will be helpful answering any questions you have about your Part D coverage determinations. If at any time, you have questions that we do not address here please call 1-833-665-5346 TTY: 711, 24 hours a day, 7 days a week.
You, your prescriber, or your representative may request a standard or expedited coverage determination by filing a written request (along with any additional information that could support your request) to Bright Health.
You can call EnvisionRx at 1-833-665-5346 TTY: 711, to request a verbal Coverage Determination or send in the completed form to:
EnvisionRx Options 2181 East Aurora Road Suite 201 Twinsburg, OH 44087 Fax # 1-877-503-7231
If you want to appoint someone to act as your representative, please refer to the How to Appoint a Representative section for additional information. Please note that your prescribing physician does not have to be your representative to help you, unless your coverage determination request is for a payment of prescription that you have already paid for.
For most pre-service requests for benefits that do not involved exceptions, Bright Health will answer your request within 72 hours (for standard requests) or 24 hours (for expedited requests). The decision will be provided verbally with a written follow-up notice sent within 3 calendar days of our phone call.
For pre-service requests for exceptions, Bright Health will answer your request within 72 hours (for standard requests) or 24 hours (for expedited requests) following receipt of your prescriber’s statement of support.
For requests for payment of prescriptions that you have already paid for, Bright Health will answer your request within 14 days after receiving your request.
If we have denied your coverage determination request, you will receive a letter from us (sometimes referred to as an unfavorable Part D coverage determination decision) where we will explain why your request could not be approved by Bright Health. Included in this letter, we will provide information on how to file a Medicare Part D Redetermination request (information found below).
This section describes how you can exercise your appeal rights under the Medicare Part D benefits of your Bright Health Medicare Advantage plan. We understand that healthcare is personal and can be complicated – that’s why we’ve put together the following Medicare Part D Redetermination Q&A for you to use. If at any time you have questions that we do not address here, please contact us at 1-833-665-5346 TTY: 711, 24 hours a day, 7 days a week.
If you have received an unfavorable Part D coverage determination decision, you can ask for a Redetermination (appeal) by following the instructions given in the coverage determination or as listed here. Redeterminations can be requested on any adverse coverage determination where you are financially liable 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.
Redeterminations are generally resolved within 7 calendar days.
Bright Health is dedicated to resolve every Part D Redetermination request quickly and accurately as possible – and many times, our answer will be faster than 7 days. If your request is pre-service and waiting could seriously jeopardize your life, a limb, or function of limb, an expedited Redetermination can be requested. These Redetermination requests are handled within 72 hours.
All appeal requests must be within 60 days of a notice of unfavorable Part D coverage decision. If your request is beyond the 60 days to file, please include the reason why you were unable to file within the time frame.
The right to appeal is for you and anyone you appoint to help you, including your prescribing physician. If you want to appoint someone, other than your prescribing physician, to help you file a Part D Redetermination request, please refer to the How to Appoint a Representative section for additional information.
Fax or mail the form below, along with any additional information that could support your Redetermination request.
Download the Redetermination of Prescription Drug Denial Request Form or fill it out online.
EnvisionRx Options 2181 East Aurora Road Suite 201 Twinsburg, OH 44087 Fax # 1-877-503-7231
Your reconsideration will be reviewed by our dedicated Part D Appeals & 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 was correct. Included in that letter will be information regarding your appeal rights with the Independent Review Entity (IRE). This Part D appeal to the IRE is called a Reconsideration and must be initiated by you, if you choose to proceed with the appeals process. Information regarding where to send this Reconsideration request will be included in our Redetermination letter. The IRE works for Medicare (not Bright Health) and they will request the Redetermination file from Bright Health and complete the Reconsideration 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.
A grievance is any complaint, other than one that involves a Plan denial of a coverage determination or an appeal. If you have a complaint regarding medical services that you have received, please click here regarding more information on how to file a Part C grievance. If you have a complaint about services in connection with your prescription coverage including but not limited to, quality of care, waiting times, or the member services you receive, you or your representative should call 1-833-665-5346 TTY: 711, to talk to someone regarding your prescription drugs.
We will try to resolve your complaint over the phone. If we cannot resolve your complaint over the phone, you may file a written grievance.
If your grievance is about the care our provider delivered (known as a Quality of Care complaint), or anything else, you can call 1-833-665-5346 TTY: 711, to get the process started.
You can also write our Appeals & Grievances department at:
EnvisionRx Options Appeals and Grievances 2181 East Aurora Road Suite 201 Twinsburg, OH 44087 Fax # 1-877-503-7231
Grievances are generally resolved within 30 calendar days from the day we receive the grievance.
You can grieve about how the process for filing, or the processing of, a Coverage Determination or Redetermination in their open state. This type of grievance is classified as a standard grievance.
If your grievance is about how you do not agree with our use of a review extension, this would be classified as a fast grievance. Under a fast grievance, we will respond to your grievance within 24 hours of receipt.
Bright Health is dedicated to resolve every grievance request as quickly and accurately as possible – and many times, our answer will be faster than 30 days.
Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
The right to grieve is for you and anyone you appoint to help you. 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 and include with your grievance letter.
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 as of the last reporting period available. To request this report, please call the Member Services number on the back of your membership card.
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 .
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 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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