Quality Assurance Policies and Procedures

Bravo Health is committed to quality – of service, of care, and of health outcomes. We have created programs that help us improve quality of service, encourage better health planning, and measure our success in meeting quality targets.

• Information on the systems in place to ensure quality health care for Bravo Health members

• 2013 Medication Therapy Management Program

Grievance, reconsideration, exceptions, coverage determination, and appeal rights and procedures

If you ever have questions about what your coverage should include, or are concerned about a denial of coverage, you can call Customer Service at 1-800-291-0396 or use these forms to submit your question or complaint.

• Request for Medicare Prescription Drug Determination Request Form(s) for Enrollees and Providers

• 
  Instructions on how to request a Medicare prescription drug coverage determination

• Coverage determination request form

• Redetermination request form

• Online Redetermination request form (to submit securely online)

• Coverage determination and/or Redetermination requests may also be sent through email.

In addition, Bravo Health wants you to have up-to-date information about how we are doing meeting member concerns. The government’s Centers for Medicare and Medicaid Services collect data on member appeals and quality-of-care complaints for Bravo Health and other insurers.

To obtain an aggregate number of grievances, exceptions and/or appeals filed with Bravo Health contact:

Regulatory Reporting Department
Bravo Health, Inc.
3601 O’Donnell Street
Baltimore, MD 21224

How to File a Grievance and/or Appeals

For more details about grievance, coverage determination (including exceptions) and appeals process, refer to Chapter 9 of the Medicare Advantage Plans with Prescription Drug coverage of your EOC or Chapter 7 of the Medicare Advantage Plan without Prescription Drug coverage and the stand-alone Prescription Drug plan of your EOC - What to do if you have a problem or complaint (coverage decisions, appeals, complaints).   For 2013 EOC, click here. You will be required to choose your state to find your plan documents, including the EOC.

To request an oral determination (exceptions)/redetermination (expedited appeal) call:

Coverage Decisions for Part D Prescription Drugs
CALL 1-800-291-0396
Calls to this number are free.
TTY 711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.

Appeals for Part D Prescription Drugs
CALL 1-866-845-6962
Calls to this number are free.
After hours, call 1-866-376-0741
TTY 711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.

Complaints about Part D Prescription Drugs
CALL 1-800-291-0396
Calls to this number are free.
After hours, call 1-866-376-0741.
TTY 711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.

To access more information on the grievance and appeals process and procedures specific to your Bravo Health plan, click below or write to the address below:

• Appeals and Grievance Process - English

• Appeals and Grievance Process - En Español

WRITE:
Bravo Health Appeals
P.O. Box 24207
Nashville, TN 37202-9910
FAX 1-866-593-4482

•  

  Coverage Decisions for Medical Care (Part C)
  CALL: 1-888-454-0013
  Calls to this number are free. You may call this number 8 am to 6pm, Mon-Fri.
  After hours call 1-800-931-0154.

• 
  TTY: 711
  This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. You may call this number 8 am to 8 pm, seven days a week.

• 
  FAX: 1-866-464-0707 (for regular and expedited)

• 
  WRITE: Bravo Health, Attn: Prior Authorization,
  1500 Spring Garden St., Suite 800,
  Philadelphia, PA 19130

  
  Appeals for Medical Care (Part C)
  

• CALL: 1-800-668-3813
  Calls to this number are free. You may call this number 8 am to 8 pm, seven days a week.
  

• TTY: 711
  This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. You may call this number 8 am to 8 pm, seven days a week.
  

• FAX: 1-800-931-0149

• 
  WRITE: Bravo Health, Attn: Appeals,
  P.O. Box 24087,
  Nashville, TN 37202-4087

  
  Complaints about Medical Care (Part C)

• 
  CALL: 1-800-291-0396
  Calls to this number are free. You may call this number 8 am to 8 pm, seven days a week.
  After hours, call 1-866-376-0741.
  
  TTY: 711
  This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. You may call this number 8 am to 8 pm, seven days a week.
  
  FAX
  1-800-931-0149
  
  WRITE
  Bravo Health, Attn: Member Grievances,
  P.O. Box 2888,
  Houston, TX 77252-2888
  

•  

Managing Your Plan and Your Benefits

The following links will take you to information that can help you better manage your plan and take advantage of your Bravo Health plan benefits.

Additional Information about Bravo Health Part D stand alone plans or Medicare Advantage plans with prescription drugs

• The Federal Government has established periods when a person can join and change their Medicare prescription drug coverage. Unless you qualify for a special election period, you can change Medicare prescription drug plans once a year between October 15^th and December 7^th

• Medicare beneficiaries may be enrolled in only one Part D plan at a time. If you are enrolled in a Medicare Advantage (MA) coordinated care (HMO or PPO) plan or a Medicare Advantage Private Fee-for-Service (PFFS) plan that includes Medicare Prescription Drugs, you may not enroll in a stand-alone Prescription Drug plan unless you disenroll from the HMO, PPO, or MA PFFS plan. If you are enrolled in a Private Fee-for-Service plan that does not provide Medicare Prescription Drug Coverage, or an MA Medical Savings Account (MSA) plan you may enroll in a PDP.

• Eligible beneficiaries must use network or contracted pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies, quantity limitations and restrictions may apply.

• Bravo Health's mail-order service requires you to order a 90-day supply. To get order forms and information about filling your prescriptions by mail, contact Customer Service. If you use a mail order pharmacy not in the plan's network, your prescription will not be covered.

• You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Bravo Health will be responsible for the costs.

Other information:

• Member rights and responsibilities

   

  Member disenrollment rights and responsibilities

• Information on how to receive a temporary supply of prescription drugs due to a change in coverage

• 2013 Plan Transition Process

You May Be Able to Get Extra Help to Pay for Your Prescription Drug Premiums and Costs

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Also, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.

For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;

• Social Security Office at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call 1-800-325-0778;

• Your State Medicaid Office.

You can find out what your monthly premium would be with Extra Help based on your plan. For more information, call our Customer Service Department at 1-800-291-0396.

• 2013 LIS Monthly Premium - Coming Soon

Best Available Evidence (BAE)

Prior Authorization Criteria for Certain Drugs

Information about drugs that require Prior Authorization (PA) or Step Therapy (ST) before being approved for coverage.

Potential for Contract Termination

• When Bravo Health must end your membership in the plan

HIPAA Privacy Notices

• Bravo Health HIPAA Notice of Privacy Practices

• Bravo Health HIPAA Notice of Privacy Practices – Spanish

• Bravo Health HIPAA Privacy Permission Form