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 prior 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.

Prior 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 Prior Authorization?

If You are receiving care from a Network Provider, the Network Provider is responsible for obtaining Prior Authorization before they provide these services to You. If the Provider fails to obtain Prior 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 Prior Authorization is obtained. Information regarding services can come from the Non-Network Provider or from You.

If you don’t get Prior Authorization, you may have to pay up to the full amount of the charges. The number to call for Prior Authorization is included on the ID card you receive after you enroll. Please refer to the specific coverage information you receive after you enroll.

Timeframe for Prior Authorization.

The Prior 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, as described below.

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.

Definitions

For purposes of this section, see the defined terms below:

Closed Panel Plan - a Plan that provides health care benefits to Covered Persons primarily in the form of services through a Provider Network that is contracted with or employed by the Plan, and that excludes benefits for services provided by Non-Network Providers, except in cases of emergency or Prior Authorization by the Plan.

Custodial Parent - the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation.

Plan - any of the following that provides benefits or services for medical, pharmacy or dental care or treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts.

  • Plan includes: group and non-group insurance contracts, health maintenance organization (HMO) contracts, closed panel plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components of long-term care contracts, such as skilled nursing care; medical benefits under group or individual automobile contracts; and Medicare or any other federal governmental plan, as permitted by law.
  • Plan does not include: hospital indemnity coverage insurance or other fixed indemnity coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non-medical components of long-term care policies; Medicare supplement policies; Medicaid policies; or coverage under other federal governmental plans, unless permitted by law.

Primary Plan - the Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with its Policy terms without consideration that another Plan may cover some expenses.

Secondary Plan - the Plan that pays after the Primary Plan is the Secondary Plan. The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Amount.

Order of Benefit Determination Rules

The order of benefit determination rules decides which Plan is Primary or Secondary when the Covered Person has health care coverage under more than one Plan.

When this Plan is primary, it determines payment for its benefits first. When this Plan is secondary, it determines its benefits after those of another Plan and may reduce the benefits it pays so that all Plan benefits do not exceed 100% of the total Allowable Amount.

Determining the Order of Benefit Payments

When a Covered Person is enrolled in two or more Plans, the rules for determining the order of benefit payments are as follows:

A. The Primary Plan pays or provides its benefits according to its terms of coverage and without consideration to benefits under any other Plan.

B. Except as provided in the next paragraph, a Plan that does not contain a COB provision that is consistent with this provision may be deemed primary unless the provisions of both Plans state that the complying plan is primary. Coverage that is obtained by virtue of membership in a group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage shall be in excess of any other parts of the Plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits and insurance type coverages that are written in connection with a Closed Panel Plan to provide out-of-network benefits.

C. A Plan may consider the benefits paid or provided by another Plan in determining its benefits only when it is secondary to that other Plan.

D. Each Plan determines its order of benefits using the first of the following rules that apply:

  • Non-Dependent or Dependent. The Plan that covers the person other than as a Dependent, for example as an employee, member, policyholder, subscriber or retiree is the Primary Plan. The Plan that covers the person as a Dependent is the Secondary Plan. However, if the person is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the person as a Dependent; and primary to the Plan covering the person as other than a Dependent (e.g. a retired employee); then the order of benefits between the two Plans is reversed so that the Plan covering the person as an employee, member, policyholder, subscriber or retiree is the Secondary Plan and the other Plan is the Primary Plan.
  • Dependent Child Covered Under More Than One Coverage Plan. Unless there is a court decree stating otherwise, plans covering a Dependent child shall determine the order of benefits as follows:
    • For a Dependent child whose parents are married or are living together, whether or not they have ever been married:
      • The Plan of the parent whose birthday falls earlier in the calendar year is the Primary Plan; or
      • If both parents have the same birthday, the Plan that covered the parent longest is the Primary Plan.
    • For a Dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:
      • If a court decree states that one of the parents is responsible for the Dependent child's health care expenses or health care coverage and the Plan of that parent has actual knowledge of those terms, that Plan is primary. If the parent with responsibility has no health care coverage for the Dependent child's health care expenses, but that parent's spouse, Domestic Partner or legal partner does, that parent's spouse's, Domestic Partner's or legal partner's plan is the Primary Plan. This shall not apply with respect to any plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision.
      • If a court decree states that both parents are responsible for the Dependent child's health care expenses or health care coverage, the provisions of subparagraph a) above shall determine the order of benefits.
      • If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the Dependent child, the provisions of subparagraph a) above shall determine the order of benefits.
      • If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows:
        • The Plan covering the Custodial Parent.
        • The Plan covering the Custodial Parent's spouse, domestic partner or legal partner.
        • The Plan covering the non-Custodial Parent.
        • The Plan covering the non-Custodial Parent's spouse, domestic partner or legal partner.
      • For a Dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph a) or b) above as if those individuals were parents of the child.
      • (i) For a Dependent child who has coverage under either or both parents’ plans and also has his or her own coverage as a Dependent under a spouse’s plan, the rule in paragraph (2) applies.
      • (ii) In the event the Dependent child’s coverage under the spouse’s plan began on the same date as the Dependent child’s coverage under either or both parents’ plans, the order of benefits shall be determined by applying the birthday rule in subparagraph (a) to the Dependent child’s parent(s) and the Dependent’s spouse.

Active Employee or Retired or Laid-off Employee

The Plan that covers a person as an active employee (an employee who is neither laid off nor retired) is the Primary Plan. The same rule applies if a person is a Dependent of an active employee and that same person is a Dependent of a retired or laid-off employee. If the other Plan does not have this rule, and, as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled D.1. can determine the order of benefits.

COBRA or State Continuation Coverage

If a person whose coverage is provided by COBRA or another right of continuation provided by state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree or covering the person as a Dependent of an employee, member, subscriber or retiree is the Primary Plan, and the COBRA or state or other federal continuation coverage is the Secondary Plan. If the other Plan does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not apply if the rule labeled D.1. can determine the order of benefits.

Longer or Shorter Length of Coverage

The Plan that covered the person the longer period of time is the Primary Plan and the Plan that covered the person the shorter period of time is the Secondary Plan.

If the preceding rules do not determine the order of benefits, the Allowable Expenses shall be shared equally between the Plans meeting the definition of Plan. In addition, This Plan will not pay more than it would have paid had it been the Primary Plan.

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.