Bright Health Transparency of Coverage.

Terms and Conditions of your policy may be affected by rules or laws applicable at the state level. Please refer to your policy for additional information.

Topics covered:

Out-of-Network Liability and Balance Billing. Enrollee Claim Submission. Grace Periods and Claims Pending. Retroactive Denials. Recoupment of Overpayments. Medical necessity and pre-authorization timeframes and enrollee responsibilities. Prescription drug exception timeframes and enrollee responsibilities. Explanation of benefits (EOB). Coordination of benefits.

Out-of-Network Liability and Balance Billing.

Benefits are not available when you use a Non-Network Provider except for emergency health services or services received from an ancillary provider at a network facility. Payment for Out-of-Network emergency services may be limited to the plan’s Allowable Amount.

This plan does not cover non-emergency services rendered by Non-Network Providers unless Pre-Authorized by Us, in the event the Bright HealthCare network of contracted providers are unable to meet the health needs of Our enrollees according to reasonable access and availability standards.

In addition, you may have to pay the difference between the plan’s allowable amount and the amount the provider bills. This is called Balance Billing. Balance Billing is the difference between the Non-Network provider's charge and the Allowable Amount for the service(s) under your plan.

For example, if the Non-Network provider's charge is $150 and Bright HealthCare’s Allowable Amount is $100, the provider may bill you for the difference of $50.

A Participating Provider may not bill you for the difference between their charge and Bright HealthCare’s negotiated rate.

Balance billing may be waived for emergency services received at a Non-Network facility.

Limitations may vary due to applicable state laws, please refer to your policy for more information.

Enrollee Claim Submission.

When a request for a claim form or the notice of a claim is provided to Us, We will provide the claimant or policyholder the claim forms required for filing. If the claimant does not receive these claim forms within 15 days after the Plan receives notice of claim or the request for a claim form, the claimant will be considered to meet the proof of loss requirement. Foreign claims must be translated in U.S. currency prior to being submitted to the Plan for payment.

Claims for Covered Health Services from a Non-Network or Non-Participating Provider must be submitted to Us within one year (365 days) from the date of service. If the Provider does not file a claim for You, You are responsible for filing the claim within the deadline. Claims submitted after the deadline are not eligible for benefit payment or reimbursement. If a claim is returned to You because We need additional information, You must resubmit it with the information requested within 90 days of receipt of the request.

Required Claim Information

When You request payment of Benefits from Us, You must provide Us with all of the following information:

• Date services were received.

• Date the Injury or Sickness began.

• ICD-10 diagnosis code from the Physician.

• ID number on Your ID card.

• Itemized bill from Your Provider that includes the Current Procedural Terminology (CPT) codes for each charge.

• Name and address of any ordering/referring Physician.

• Name, address, Tax ID, and NPI number of the Provider of the service(s).

• Patient's name and date of birth.

• Statement indicating that You either are or are not enrolled for coverage under any other health insurance plan or program. If You are enrolled for other coverage You must provide the name of the other carrier(s) and Your ID number for the other coverage.

• Subscriber's name and address.

North Carolina:

Claims for Covered Health Services from a Non-Network or Non-Participating Provider must be submitted to US within 180 days after the date of the provision of care to the patient by the health care provider and, in the case of health care provider facility claims, within 180 days after the date discharge from the facility. Failure to submit a claim within the time required does not invalidate or reduce any claim if it was not reasonably possible for the claimant to file the claim within that time, provided that the claim is submitted as soon as reasonably possible and in no event, except in the absence of legal capacity of the insured, later than one year from the time submittal of the claim is otherwise required.

Claims can be submitted to Us at:

Bright Health Insurance Company
P.O. Box 16275
Reading, PA 19612

Download our Bright HealthCare Member Claim Form here.

Download our Bright HealthCare Commercial Prescription Reimbursement Claim Form here.

Grace Periods and Claims Pending.

What is a grace period?

A grace period is a designated period of time immediately following the due date of your monthly premium. We will pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period. If your premium is paid during the grace period, coverage will remain in effect. If your premium is not paid during the grace period, coverage will terminate.

A Grace Period of 3 months for individuals receiving federal insurance subsidies will be allowed for the payment of all outstanding premiums. If the full balance of outstanding premium is not paid within Your grace period, coverage will end on the last day of the first calendar month of the grace period. For non-subsidized Members, a 31-day grace period will be allowed for the payment of all outstanding premiums. If the full balance of outstanding premium is not paid within Your grace period, coverage will end on the last day for which You have paid Your premium. We will provide You notice of Your nonpayment before cancelling Your Policy. We will not pay for any services received on or after the date Your coverage ends.

What is a pending claim?

A pending claim is a claim that remains in a “hold” or “pending” status. This means the claim will not be paid or denied until specific action is taken.

Retroactive Denials.

A retroactive denial is the reversal of a previously paid claim, through which the enrollee then becomes responsible for payment. Claims may be denied retroactively, even after the enrollee has obtained services from the provider. Ways to prevent retroactive denials, when possible:

  • Pay your monthly premium on time
  • Present your ID card when you receive services. Make sure your provider has your current insurance information.
  • Stay in-network, if required by the plan
  • Get prior authorization, if required by the plan

What to do if your claim is retroactively denied:

  • You will find information about how to appeal in your policy

Recoupment of Overpayments.

How to get a refund if you paid too much for your insurance?

If you overpaid your insurance premium you may qualify for a refund. If you think you overpaid, We can help you. Please call the number on the back of your ID card with questions about your premium payment and a possible refund.

Medical necessity and pre-authorization timeframes and enrollee responsibilities.

Some services covered by Your plan may require Prior Authorization and review for Medical Necessity before you receive care. Medical Necessity is used to describe care that is reasonable, necessary and appropriate based on evidence-based clinical standards of care.

Pre-authorization is the process of reviewing a request for health care services for Medical Necessity and network affiliation prior to You receiving those services.

Who is responsible for obtaining Pre-authorization?

If You are receiving care from a Network Provider, the Network Provider is responsible for obtaining Pre-authorization before they provide these services to You. If the Provider fails to obtain Pre-authorization and the service is denied, he or she may not balance bill You.

If You are receiving care outside of Your Service Area, or care from a Non-Network Provider, You are responsible for making sure that Pre-authorization is obtained. Information regarding services can come from the Non-Network Provider or from You.

Timeframe for Pre-Authorization.

The Pre-authorization review process requires the full cooperation of the requesting Physician in order for Us to evaluate all of the pertinent information and make a coverage determination. We must make Our decision within 15 calendar days of receiving the Prior Authorization request and Physician’s statement. You can request an expedited exception if you or your Physician believe that your health could be seriously harmed by waiting 15 calendar days for a decision. If your request to expedite is granted, We must give you a decision no later than 72 hours after We get the supporting statement from your Physician.

Prescription drug exception timeframes and enrollee responsibilities.

Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). Exceptions may be granted in certain circumstances or for emergency or special situations.

Exception or non-formulary requests are initially reviewed by us through the formulary exception review process. Your prescriber or doctor and pharmacy staff will need to provide certain information in order for Us to review an exception request . Your prescriber or pharmacy staff can submit the request to us by faxing the Coverage Determination Request Form.

If the drug is denied, you will be notified of your appeals process, in writing. You can also find information about the exceptions process for prescription drugs in your Certificate of Coverage policy document.

To request an expedited review for exigent circumstance, select the “Expedited/Urgent” box on the Request Form.

If the plan does not cover your medication or has restrictions or limits on your medication that You don’t think will work for You, You can do one of the following:

  • Ask Your health care provider if there is another covered medication that will work for You; or
  • Your health care provider can ask the plan to make an “exception” to cover a medication or to remove medication restrictions or limits.

Examples of exceptions are:

  • The medication that is normally covered has caused a harmful reaction to You;
  • There is a reason to believe the medication that is normally covered would cause a harmful reaction; or
  • The medication prescribed by Your qualified health care provider is more effective for You than the medication that is normally covered.

Exceptions for brand drugs may be approved because less costly equivalent alternatives are not available. If a lower cost equivalent brand, generic, or biosimilar becomes available as a preferred drug, only the preferred drug will be covered.

Drugs determined by our Pharmacy & Therapeutics Committee to be deficient are excluded from the Formulary exceptions process.

New drugs to market that have not been reviewed by our Pharmacy and Therapeutics Committee are excluded from the formulary exceptions process, and coverage, until reviewed for safety, efficacy, and uniqueness by our Pharmacy and Therapeutics Committee.

The medication must be in a class of medications that is covered. For additional information about the prescription drug exceptions processes for drugs not included on Your plan’s Formulary, call the Pharmacy Customer Services number on Your ID Card.

For standard exception requests, We must make a determination and notify You and the prescribing physician no later than 72 hours following Our receipt of the request for exception. If We grant a standard exception request, We must provide coverage of the non-formulary drug for the duration of the prescription, including refills.

Expedited exception requests are appropriate for exigent circumstances, which means the person for whom the request is being made is suffering from a health condition that may seriously jeopardize their life, health, ability to regain maximum function, or the person is undergoing a current course of treatment using a non-formulary drug.

For expedited exception requests, We must make a determination and notify You and the prescribing physician no later than 24 hours following Our receipt of the request for exception.

If we grant an approval of an exception request, we will provide coverage until the authorization expires.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision. An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing a request for external review. You can find information on how to request an external review in your policy, by contacting us at the phone number listed on your ID card, or by logging in to the Member Hub at brighthealthcare.com/member.

For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request.

For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form.

For additional information about the prescription drug exceptions processes for drugs not included on Your Plan’s Formulary, please contact the Pharmacy Customer Services number on Your ID Card.

Explanation of benefits (EOB).

An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy.

How do you know if We paid a claim?

Your doctor's office submits a claim for payment to Us after you receive care. If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card.

After the claim is processed, We will provide an Explanation of Benefits (EOB) to you. We send this statement to explain what medical treatments and/or services were paid. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. It’s simple and clear, so you can see what was submitted, what’s been paid and what you owe. EOBs are available for you to look at online at www.brighthealthcare.com.

Coordination of benefits.

Please note: Coordination of Benefits is not allowed for individual plans sold by Bright Health of North Carolina. The following language does not apply to plans sold by Bright Health of North Carolina.

When Does Coordination of Benefits Apply?

This Coordination of Benefits (COB) provision applies when a Covered Person has health care coverage under more than one Plan.

An important part of coordinating benefits is determining the order in which the plans provide benefits. The plan who provides benefits first is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about COB can be found in your policy.

Other Insurance Coverage - when the other plan is also with Us.

If you are covered by more than one of Our qualified health plans, you will receive the benefits of only one plan. You may choose the plan under which you will be covered. We will refund any premium received under the other plan. Any claims payments made by us under the plan you choose to cancel will be deducted from any such refund of premium.