Transcription
2022ProviderResourceGuidei
What’s inside?Introduction. 1Keeping your information up to date.2Make the most of Availity.3Utilization Management and prior authorizations.5Submitting claims.7Receiving payments. 8Provider FAQ.9Quick Reference Guide.11New for 2022, justone Payer ID for allclaims: BRGHT
The provider roadmapThis guide is designed to help you easily navigate the process of partneringwith Bright HealthCare .Make sure your data and roster are up to datePrepare to see Bright HealthCare membersLearn about member eligibilityEnsure in-network careRequest prior authorizations, if neededSee Bright HealthCare membersFollow up with in-network care or a network navigatorSubmit and track your claimGet paid
We’re glad you’re hereAt Bright HealthCare, we believe healthcare should be simple, personal, and more affordable.Our health plans are built around comprehensive, clinically integrated networks to ensure ourmembers get quality care from a connected group of high-performing providers.We know the relationship between a patient and their provider is at the heart of qualityhealthcare. That’s why we focus on offering unparalleled support to our provider networks—so you can spend less time on health insurance and more time with your patients.Simple, personal, affordableA better experience foryou and your patientsTo support the provider-patient connection,we built our plans around three core principles: 0 copays for routine preventive care visitsencourage patients to visit their providerregularly and to maintain their health.Simple: We created a close network ofproviders and hospitals to give our membersaccess to superior, quality care. For ourproviders, our streamlined online access tothe information and services you need helpsyou create the best care experience foryour patients.Wherever possible, our plans feature copaysover coinsurance, so you can collect paymentat the point of care.Our high network retention rates improve ournetwork quality, enhance care affordability,and support appropriate benefit use. BrightHealthCare quickly becomes a trusted partnerfor our providers!Personal: We take pride in being there foryou and your patients, where and when youneed it. Live support is available through ourMember and Provider Services hotlines, andwe have dedicated local Provider RelationsRepresentatives who understand yourcommunity and needs.We offer electronic claims management, astreamlined prior authorization process, andeasy eligibility and benefit checks so yourstaff can spend less time on paperwork.Affordable: Our carefully selected networkspromote coordinated care and efficient use ofresources. We pass these savings along to ourmembers, which lowers their out-of-pocketcosts and reduces barriers to care.1
Keeping yourinformation up to dateTo ensure providers are accurately listed in our Provider Directory,your office must report provider adds, terms, and changes 30 daysprior to change effective date. The Bright HealthCare template canbe found on Availity.com under the 2022 Resources Categorywithin the Payer Spaces tab (Roster Updates).!If you are contracted with Bright HealthCare through alarger organization, please notify them directly of anychanges to your provider data roster and they will notifyBright HealthCare on your behalf. You do not need tocomplete the process outlined below.Add: A provider is addedto a rosterTerm: A provider is removedfrom a rosterChange: An existing providerhas a change in any of theirdemographics/credentials.To ensure timely updates to the Bright HealthCare Provider Directory,please make sure to follow these Roster and email guidelines:You used the Bright HealthCare Roster Upload (available on Availity.com).Your updated roster is a complete, active view of all the providers that are a part ofyour contract with Bright HealthCare. Our database system will analyze the full activeroster for adds, changes, and terms. If you are unsure which roster Bright HealthCarehas on file for you, please email your appropriate state contact (listed below).You used the email template below.Email templateSubject line: Roster Update: [Company Name as it appears on your Bright HealthCare contract]Send to: [The appropriate state email address as listed below]Email: Roster updates attached for [Company Name as it appears on yourBright HealthCare contract].Tax ID: [Number] (Note: We use the tax ID to ensure we are updating the correct contractedentity. If you have multiple IDs, please only provide the ID you sent to us previously.)State-specific email addressesAlabama: providerdataAL@brighthealthplan.comArizona: providerdataAZ@brighthealthplan.comCalifornia: providerdataCA@brighthealthplan.comColorado: providerdataCO@brighthealthplan.comFlorida: providerdataFL@brighthealthplan.comGeorgia: providerdataGA@brighthealthplan.comIllinois: providerdataIL@brighthealthplan.comNebraska: providerdataNE@brighthealthplan.comNew York: providerdataNY@brighthealthplan.comNorth Carolina: providerdataNC@brighthealthplan.comOhio: providerdataOH@brighthealthplan.comOklahoma: providerdataOK@brighthealthplan.comSouth Carolina: providerdataSC@brighthealthplan.comTennessee: providerdataTN@brighthealthplan.comTexas: providerdataTX@brighthealthplan.comUtah: providerdataUT@brighthealthplan.comVirginia: providerdataVA@brighthealthplan.comNational: providerdatanational@brighthealthplan.com2
Make the most of AvailityAs a Bright HealthCare provider, you’re probably familiar with Availity.com and use it regularly.We want you to have the best Availity experience, cut down on your admin work, and preventpotential issues.Member eligibility checksPrior authorizationsMembers receive ID cards upon enrollment.Before providing service, you must verify activecoverage by checking member eligibility andbenefits through Availity. If you’re unable toaccess Availity, you may contact ProviderServices:The option to submit prior authorizationselectronically through Availity varies by state.For specific prior authorization resources,go to nt.IFP for CA, GA, TX,UT, VAIFP for AL, AZ, CO,FL, IL, NC, NE, OK,SC, TNMA (all statesexcept CA)Small GroupUp to 12/31/21Effective 1/1/22844-926-4524844-926-4525If you are unable to connect to submit anauthorization, you may not be registeredwith Bright HealthCare. Please contact yourProvider Services Representative.Payer Spaces tab866-239-7191844-926-4521Find important announcements and helpfulresources by clicking on the Payer Spaces taband then selecting Bright HealthCare. Youwill find things like:844-926-4522855-521-9364Here are more tips for successful eligibility checks: Billing and coding updates Enter information in the Availity webformexactly as it appears on the member ID card.Be especially careful the member’s nameis entered correctly, as the lookup tool willnot account for missing hyphens, shortenednames, etc. Welcome Guide! Quick Reference Guide Provider ManualClaim statusDon’t have the right member ID? Go toBrightHealthCare.com/provider/resources tofind it. Also, you may contact Provider Servicesfor assistance with member ID issues. Pleaserefer to the appropriate Provider Services line inyour state within this document.Availity allows you to easily check the statusof a claim. Always enter the NPI from theservice provider field exactly as it wassubmitted on the claim (rendering provider),not the billing provider! Payer Option: Starting 1/1/2022, justselect “Bright Health Plan” from the Payerdrop-down menu. To view an IFP member’s primary careprovider (PCP) benefits, look up service type98 – professional (physician) visit – office. To view an IFP member’s specialty benefits,look up service type 96 – professional(physician) visit – specialty.3Don’t know the rendering provider’sNPI? Contact your organization’s ITor support team.
Common issuesVisit Availity.com to:Verify member eligibility and benefitsYou can’t register for AvailityContact the person who manages yourprovider roster and ask them to updateregistered NPIs. They can contact Availitycustomer service if they have problemsuploading a roster.File claims electronicallyFind claim submission details inthe Provider Manual or the QuickReference Guide, both of whichare on Availity.com under thePayer Spaces tab-search for 2022Resources. You can also submitclaims via mail (see addresses underSubmitting Claims on page 7). Wedo not accept faxed claims.You’re having technicalissues with the websiteClick on Help & Training tab Availity support.You receive an errorwhen you look up claimsCheck claims status and viewremittance informationConfirm you’re using the correct memberID and NPI. If you are using a third-partysoftware or EDI clearinghouse, contactyour IT group to confirm that requests aresubmitted to Payer ID: BRGHT.Submit and track prior authorizationsin a fast and efficient manner. Viewthe Utilization Management & PriorAuthorization page in this ResourceGuide to learn more.2022 Payer ID:View news, tools, and resourcesStarting 1/1/2022, all claims (excludingCalifornia Medicare Advantage) must besubmitted to payer ID: BRGHT.Access the Provider Manual,Quick Reference Guide, formulary,prior authorization lists, UtilizationManagement protocols, andCertificates of Coverage (COCs).!Still having issues? Please submit yourquestions in Availity. For help with this,contact your Provider RelationsRepresentative.New to Availity? Register online.1. Visit Availity.com2. Click the Registerbutton in the top right3. Select your organization type4. Enter your informationInterested in learning more about what Availitycan do? Check out the Help and Training tab onAvaility.com Help & Training Payer Help fortutorials and guides.If your practice already has an account, yourpractice’s administrator will need to addnew users. If you do not know who that is,please contact Availity Client Services at800-282-4548 Monday-Friday, 8 AM–8 PMEastern.NOTE: The application process happens inreal time. Once the application is approved,you will be able to see Bright HealthCare onthe Availity home page.4
Making care simple,personal, and affordableBright HealthCare’s Utilization Management programOur Utilization Management (UM) program exists to promote care that is evidence-based,affordable for your patients, and a cost-effective use of healthcare resources.What does prior authorizationmean at Bright HealthCare?At Bright HealthCare, prior authorization determines coverageon certain services and products by confirming in-networkstatus of the provider or facility and/or medical necessity basedon a clinical review. Not all prior authorizations require a medicalnecessity review.What do I need to know about theBright HealthCare UM program?Take a moment to familiarize yourself with the requirementsfor services commonly performed by your practice by visitingour website at t. You will find UM resources including detailed listsof procedure codes that require prior authorization, a link to ourAuthorization Navigator, online authorization portal information,fax forms, and other resources. This information can also befound on Availity Payer Spaces.1. Log on to Availity.com.2. Select your state in the drop-down menu.How do I submitprior authorizations?The process for submittingprior authorizations varies bystate. For state-specific priorauthorization resources, goto t.NOTE: Providers andfacilities who are notin-network with BrightHealthCare need to submitauthorization for all servicesand procedures.3. Select Bright HealthCare under Payer Spaces.4. Find Prior Authorization Service Code list for designatedline of business (IFP/SG, MA).This can also be found on the Bright HealthCare website ment!A comprehensive list of services requiring a prior authorization can be found by visitingAvaility.com Click on your state Go to Payer Spaces Search for Code List documents.5
What are the turnaround times for prior authorization decisions?Individual & Family and Small Group Plans — Utilization Review TimelinesStandard ProspectiveUrgent ProspectiveConcurrentRetrospective15 calendar days72 hours24 hours30 calendar daysStates following the timelines above: Alabama, Arizona, Florida, Georgia, Nebraska, Oklahoma, UtahUnique State RequirementsStateStandard ProspectiveUrgent ProspectiveConcurrentRetrospectiveCalifornia5 business days72 hours24 hours30 calendar daysColorado5 business daysLesser of 2 business days or 72 hours24 hours30 calendar daysIllinois5 calendar days48 hours24 hours30 calendar daysNorth Carolina3 business days72 hours24 hours30 calendar daysSouth Carolina2 business daysLesser of 2 business days or 72 hours24 hours2 business daysTennessee2 business daysLesser of 2 business days or 72 hours24 hours30 calendar daysVirginia2 business daysLesser of 2 business days or 72 hours24 hours2 business daysTexas — Utilization Review TimelinesUrgent ProspectiveStandard ProspectiveUrgent ConcurrentRetrospective72 hours3 calendar days24 hours for hospitalizedpatients; 3 calendar days fornon-hospitalized patients30 calendar daysMedicare Advantage — Utilization Review Timelines (Calendar Days)TypeProcessing TimelineWith Extension14 days28 daysPre-Service Expedited/Urgent72 hours17 daysPost-Service30 daysN/APart B Drug72 hoursN/APart B Drug – Expedited24 hoursN/APre-Service Standard6
Submitting claimsBright HealthCare makes it easy to submit claims.Availity.comLog in to your Availity account to submit electronic claims. You canfind submission details in your Provider Manual and the Provider QuickReference Guide, which are both located on Availity.Via EDI connection!Effective 1/1/2022, the new Payer ID for all Bright HealthCare plans(excluding California Medicare Advantage) is BRGHT.Alternate methodWhile Bright HealthCare encourages providers to submit claimselectronically, you can also submit claims by mail:Medicare Advantage for thestates of AZ, CO, FL, IL, and NY:(services up to 12/31/2021)Medicare Advantage for thestates of AZ, CO, FL, IL, and NY:(2022 services effective 1/1)Bright HealthCare MA—ClaimsP.O. Box 853960Richardson, TX 75085-3960ANDCommercial IFP for the statesof CA, GA, TX, UT, and VA:(2022 services effective 1/1)Commercial IFP & Small Group forthe states of AL, AZ, CO, FL, IL, NC,NE, OK, SC and TN:Bright HealthCare ClaimsP.O. Box 211502Eagan, MN 55121Bright HealthCare ClaimsP.O. Box 16275Reading, PA 19612-6275Bright HealthCare does not accept faxed claims.7
Receiving paymentsEffective 1/1/2022, Bright HealthCare uses InstaMed to process claim payments forMedicare Advantage in AZ, CO, FL, IL, and NY; and Commercial IFP in CA, GA, TX, UT,and VA. If you have previously enrolled with InstaMed, Bright HealthCare will send youElectronic Funds Transfers by default.V-Pay is used for commercial claim payments for the states of AL, AZ, CO, FL, IL, OK,NC, NE, SC, and TN.All vendors meet state and federal requirements for electronic payments and areHIPAA compliant. Follow the steps below to get set up.Using InstaMedUsing V-Pay Register at www.instamed.com/eraeft.Once your first claim is processed,you will receive a notification askinghow you wish to receive payment(Electronic Funds Transfers, PaperCheck, V-Card) and remittancenotifications (835, EOP, etc.). Once registered you are eligible toreceive electronic claims payment. For assistance on Electronic FundsTransfers, please call 866-945-7990to reach a live representative, or emailInstaMed at connect@instamed.com.Explanations of Provider Payment (EOP)InstaMed Log into Availity to review your EOP. Or register with InstaMed to receive accessto InstaMed Online, a free, secure provider portal where you can access paymentdetails 24/7 and view and print remittances. You also have the option to have EOPs routed to your existing clearinghouse. Also, you may choose to have an SFTP folder set up. Please contact InstaMed atconnect@instamed.com for help or with any questions on EOP delivery.V-Pay You can choose how you’d like to receive your EOP. V-Pay can send them via fax,mail, or as 835 remittance advice.8
FAQ aboutBright HealthCare,plans, and resourcesHow can I check member eligibility and benefits?When can I start seeingBright HealthCare patients?You can check member eligibility and benefitson Availity.com. The following information isrequired:You can start seeing active members onceyou receive confirmation that you have passedcredentialing AND once the plan is live (1/1/22 forCA, GA, TX, UT, and VA). Plan effective date andother contract terms can be found in your practiceor organization’s completed Network ParticipationAgreement. Please contact your ProviderRelations Representative with any questions. Requesting provider’s NPI Member ID Member first and last name Member date of birthIf you have additional questions about membereligibility, please contact Provider Services.How can I find out if my providershave been credentialed?How do we update our provideror practice information?Once a Direct Credentialing (vs. DelegationCredentialing) decision has been made, youwill receive a letter notifying you of that decisionwithin 10 days. If it has been more than 90days since your provider has been submittedfor credentialing and you have not received aletter, please contact the Bright HealthCareCredentialing team at credentialing@brighthealthplan.comVisit NPPES.CMS.hhs.gov to update yourNPPES profile. Your NPPES profile collectsall your information in one place and makes itavailable to all your payors, saving you time andenergy. Visit BrightHealthCare.com/provider tolearn more about how to update your NPPESprofile or how to send a roster directly to us.The information we currently have on filecomes from the roster you provided when wecontracted with your practice, but we’re alwaysworking to improve our provider data usingsources like NPPES.Where can I find a copy of theBright HealthCare Provider Manual?Starting 1/1/2022, you can find the 2022Provider Manual on Availity.com under theBright HealthCare Payer Spaces tab.See Keeping your information up to date onpage 2. Since we may augment our recordswith NPPES data in order to expedite approvalsand claim processing and payments, please besure to keep your NPPES data up to date. Forroster updates instructions, see: es/BrightHealthCare Rosters 2022.pdf.Why can I not see my provider in the onlineBright HealthCare Provider Directory?Please confirm that your provider has passedcredentialing through Bright HealthCare. If theyhave and are not appearing in the Directory,please contact your local Provider RelationsRepresentative.9
How do I submit prior authorizations?How can I check the status of a claim?For prior authorization resources, gement or Availity.com.Claims status can be checked on Availity.com.For additional support, please contactProvider Services.Where do I submit claims?Where can I find our fee schedule?Professional and facility claims can besubmitted online through Availity.comor through any other electronic datainterface (EDI) clearinghouse. Informationon filing claims via mail can be found onBrightHealthCare.com/provider or underSubmitting Claims on page 7. Claimscannot be submitted via fax.Please refer to your completed NetworkParticipation Agreement for a full fee schedule.If you have questions about your fee schedule,please contact your local Provider RelationsRepresentative. If you are contracted with BrightHealthCare through a larger organization, pleasecheck with your contact at that organization.What kinds of health insuranceplans are you offering in my area?How do I reduce requestsfor Medical Records?Starting now, you can find full product detailsby service area on BrightHealthCare.com.Let us do the work! You can give BrightHealthCare access to your electronic medicalrecord (EMR) system so we can directly obtainthe data we need and prevent the need forchart requests later in the year. Our goal isto reduce your administrative burden, andby providing us this access we can supportyou. If you are interested, please email us atmedicalrecords@brighthealthcare.com.Where can I view providerresources and announcements?Visit BrightHealthCare.com/provider foraccess to resources, announcements,and updates.Visit Availity.com Payer Spaces BrightHealthCare News and AnnouncementsCalifornia IFP plans:Bright HealthCare will inform contracting providers that informational notices explaining how enrollees may contactBright HealthCare, file a complaint with Bright HealthCare, obtain assistance from the Department and seek anindependent medical review are available in non-English languages through the Department’s web site. The notice andtranslations can be obtained online at www.hmohelp.ca.gov for downloading and printing. In addition, hard copies maybe requested by submitting a written request to: Department of Managed Health Care, Attention: HMO Help Notices,980 9th Street, Suite 500, Sacramento, CA 95814.10
Quick Reference GuideAvaility.comManage claim submission, prior authorizations, and access resources.Provider ServicesIFP for CA, GA, TX, UT, VAUp to 12/31/2021Effective 1/1/2022844-926-4524844-926-4525IFP for AL, AZ, CO, FL, IL, NC, NE, OK, SC, TNMA (all states except CA)866-239-7191844-926-4521Small Group844-926-4522855-521-9364ClaimsCheck claim status: Visit Availity.com or callProvider Services. (Availity also allows you toview remittance notices on electronically paidclaims, and you can register to receive thesenotices electronically.)tear off hereBright HealthCare does not acceptfaxed claims.Providers can submit a paper claim orelectronically, through Availity or EDIClearinghouses (Edmeon, Gateway, RelayHealth, and other EDI Clearinghouses).Provider dispute resolution: For issues thatdo not involve routine inquiries resolved in atimely fashion through informal processes,we offer a provider dispute process foradministrative, payment, or other disputes thatyou may have. Dispute categories include:Medicare Advantage for AZ, CO, IL, NY:(services up to 12/31/2021)Bright HealthCare MA ClaimsP.O. Box 853960Richardson, TX 75085-3960Commercial IFP & Small Group forAL, AZ, CO, FL, IL, NC, NE, OK, SC, TN:Bright HealthCare ClaimsP.O. Box 16275Reading, PA 19612-6275 Medicare Advantage for AZ, CO, FL, IL, NY:(2022 services effective 1/1) ANDPayment disputesContractual denialsAllowable rate disputesMedical necessity denialsMissing prior authorizationBy using our provider disputes form, you avoiddelays and receive an acknowledgement witha case number. You may access the disputesform on our Provider Resource page: mercial IFP for CA, GA, TX, UT, VA:(2022 services effective 1/1)EDI Payer ID: BRGHTMail to:Bright HealthCare ClaimsPO Box 211502Eagan, MN 55121Please refer to your provider manual or contactProvider Services with any questions.Discuss claim payment options: IFP in AL, AZ, CO, FL, IL, OK, NC, NE, SC, TN: 877-714-3222 or email support@payusa.com Medicare Advantage (all states except California) and Commercial IFP in CA, GA, TX, UT, VA,effective 1/1/2022: 866-945-7990 or email connect@instamed.comBright HealthCare and the Bright HealthCare logo are trademarks of Bright Health Group, Inc.11
Eligibility & benefitsPrior authorizationsVerify member eligibility and benefits:Availity.com or Provider Services RequiredinformationTo see the list of services requiring anauthorization, download forms, checkrequest status, or submit an electronicprior authorization*, visit Availity.com. Requesting provider’s NPIMember IDMember first and last nameMember date of birth* Note: The option to submit prior authorizationselectronically through Availity varies by state.For specific prior authorization resources, goto t.Download Certificate of Coverage andSchedule of Benefits: Availity.comQuestions?Call your state’s Provider Services numberand select “Utilization Management.”Contracting, credentialing,& roster questionsIndividual & Family Plans for AL,AZ, CO, FL, IL, NC, NE, OK, SC, TN:Obtain a fee schedule or inquire aboutcontract effective date:Individual & Family Plans for CA, GA,TX, UT, VA: 844-926-4525 If you’re directly contractedwith us: Contact your ProviderRelations Representative (PRR) If you’re contracted through alarger organization: Contactorganization directly866-239-7191Small Group plans for AZ, CO, NC, NE,TN: 855-521-9364Medicare Advantage plans for AZ, CO,FL, IL, NY: 844 926 4522Update provider roster:Pharmacy questions Obtain a formulary: Availity.com If you’re directly contracted with us:refer to BrightHealthPlan.com/provider/get-started to access your specificmarket email address.Prescriber services:Medicare: 833-726-0667Individual & Family: 833-726-0670Small Group: 833-726-0670If you’re contracted through a largerorganization: Notify organization directlyQuestions about credentialing:2022 IFP Formularies:Email the Bright HealthCare Credentialingteam at e.com/individual-and-family/drug-search2022 MA e/drug-searchProvider DirectoryLocate in-network providers/facilities:Use our Provider Finder toolMedicare: BrightHealthCare.com/searchCommercial: BrightHealthCare.com/search12
Obtain the Provider ManualComplaints & grievancesAvaility.com: Bright HealthCare Payer Spaces tabMedicare for all states except CA:Bright HealthCareAppeals and GrievancesP.O. Box 1868Portland, ME 04104Sample ID cardsEffective 1/1/2022, visit BrightHealthCare.com/provider/resources to view sample ID cards.IFP for in CA, GA, TX, UT, VA:Bright HealthCareAppeals and GrievancesP.O. Box 1519Portland, ME 04104Member ServicesBright HealthCare is here for your patients.Refer your patients to the contacts belowif they have any questions.IFP for AL, AZ, CO, FL, IL, NC,NE, OK, SC, TN:Bright HealthCareAppeals and GrievancesP.O. Box 16275Reading, PA 19612Medicare: 844-926-4521Oct 1–March 31, 8 AM–8 PM local time,Mon–Sun (excluding federal holidays)Apr 1–Sept 30, 8 AM–8 PM local time,Mon–Fri (excluding federal holidays)IFP for AL, AZ, CO, FL, IL, NC, NE, OK,SC, TN: 855-827-4448Mon–Fri, 8 AM–8 PM local timeProvider disputesIFP for CA, GA, TX, UT, VA: 844-926-4524Mon–Fri, 8 AM–8 PM local timeCase ManagementUse our online provider disputesform to avoid delays and to receivean acknowledgement with a casenumber: https://providerinquiries.brighthealthcare.com.To refer a patient to a case manager:For regular mail:Medicare: 888-668-0804Mon–Fri 8 AM–5 PM Central timeMedicare for all states except CA:Bright HealthCareProvider DisputesP.O. Box 1359Portland, MEIFP for AL, AZ, CO, FL, IL, NC, NE,OK, SC, TN: 888-658-6818Mon–Fri, 8 AM–5 PM Central timeIFP for AL, AZ, CO, FL, IL, OK,NC, NE, SC, TN:Bright HealthCareProvider DisputesP.O. Box 16275Reading, PA 19612-6275IFP for CA, GA, TX, UT, VA: 844-926-4525Mon–Fri, 8 AM–5 PM Central timeSmall Group: 855-521-9365Mon–Fri 8 AM–8 PM local timeIFP for CA, GA, TX, VA, UT:Bright HealthCareProvider DisputesP.O. Box 836Portland, ME 0410413
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Bright HealthCare and the Bright HealthCare logo are trademarks of Bright Health Group, Inc.ALL-DM-5295
coverage by checking member eligibility and benefits through Availity. If you’re unable to access Availity, you may contact Provider Services: Here are more tips for successful eligibility checks: Enter information in the Availity webform exactly as it appears on the member
