Frequently Asked Questions
Why should I submit electronically?
Submitting authorizations electronically is faster, easier and accessible via a free, secure portal. Benefits of submitting authorizations electronically include:
- Receive immediate confirmation that a request was submitted successfully
- Receive a reference number for each authorization
- Able to view the status of an authorization
- Ability to submit clinical documentation
- Able to view determination letters for any authorization
When will my authorization be processed?
| MA Utilization Review Timelines | |
|---|---|
| MA Request Type | Processing Time |
| Urgent Pre-Service | 72 hours |
| Urgent Part B Drug | 24 hours |
| Routine Pre-Service | 14 calendar days |
| Routine Part B Drug | 72 hours |
| Urgent Concurrent | 72 hours |
| Post-Service (Retro) Will accept if submitted with in 365 days from DOS | 30 calendar days |
| IFP Utilization Review Timelines | |||||
|---|---|---|---|---|---|
| State | Routine PreService | Urgent PreService | Routine Concurrent | Urgent Concurrent | Retrospective |
| California | 5 business days | 72 hours | 24 hours | 30 calendar days | |
| Georgia | 15 calendar days | 72 hours | 24 hours | 30 calendar days | |
| Texas | 72 hours | 72 hours | 24 hours from receipt of complete clinical documentation with Request 72 hours if complete clinical documentation is not received | 30 calendar days | |
| Utah | 15 calendar days | 72 hours | 24 hours | 30 calendar days | |
| Virginia | 2 business days | 2 business days | 24 hours | 2 business days | |
How do I get help?
For any questions or concerns, please contact Evolent provider services at
- MA Plans: Phone: 1-844-926-4522 Fax: 1-888-337-2174
- IFP Plans: Phone: 1-844-926-4525 Fax: 1-877-438-6832
When are reviews needed?
- Inpatient and Outpatient Services (Medical and Mental Health)
- Before Services are Performed (Pre-service/prospective)
- During Service Period (Concurrent)
- After service was performed (Retro)
When will my authorization be processed?
| Utilization Review Timelines | ||||
|---|---|---|---|---|
| Category | Standard | Urgent | Concurrent | Retrospective |
| URAC Standard | 15 calendar days | 72 hours | 24 hours | 30 calendar days |
| States following URAC: Alabama, Arizona, Florida, Illinois, Nebraska, Oklahoma, Tennessee | ||||
| Unique State Requirements | ||||
|---|---|---|---|---|
| North Carolina | 3 business days | 30 calendar days | ||
| Colorado* | 5 calendar days | Less of 2 business days/72 hours | 24 hours | 30 calendar days |
| South Carolina | 2 business days | 1 business day | 30 calendar days | |
| *Turnaround times apply so long as complete documentation is submitted with the prior authorization request in order to make a determination. | ||||
For faster processing: Please include all pertinent clinical documentation to substantiate medical necessity of the requested service.
Details and documentation may include:
- Reason the study is being requested (e.g., further evaluation, rule out a disorder)
- Symptoms and their duration, physical exam findings and progress notes, initial or follow-up screening (if follow-up, include outcome of previous screening and date)
- Conservative treatment (and its attempted duration) patient has already completed (e.g., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs, medications)
- Preliminary procedures already completed (e.g., x-rays, CTs, lab work, ultrasound, referrals to specialist)
- Items/services are related to a confirmed rare disease diagnosis per NIH/National standards.
What do I do if I receive a denial?
In the event that you receive a denied prior authorization request you may request to:
- Complete a Peer to Peer reconsideration.
To schedule a peer to peer, please call : Calling 1-844-990-0375
Bright Health Clinical Services - English 1 or Spanish 2
You will hear: Thank you for calling Bright Health Clinical Services. If this is a medical emergency, please call 911. If you are a Provider currently servicing a member that lives in the state of Oklahoma, press 5. Otherwise please select from the following options: For Prior authorizations and Inpatient Concurrent Review, Press 1. For Help finding an in network physician, Press 2. For Appeals & Grievances, Press 3. For Physician Peer Review, Press 4. If you know your party’s extension, please enter now. For all other calls, press 9 and a member of your Bright Health team will be with you shortly - File an appeal
You may request an appeal without completing a Peer to Peer or following. All appeals must be in writing and the packet for submission will be included with your authorization denial.
If you need to speak to the Appeals team, you may reach them by: Calling 1-844-990-0375
Bright Health Clinical Services - English 1 or Spanish 2
You will hear: Thank you for calling Bright Health Clinical Services. If this is a medical emergency, please call 911. If you are a Provider currently servicing a member that lives in the state of Oklahoma, press 5. Otherwise please select from the following options: For Prior authorizations and Inpatient Concurrent Review, Press 1. For Help finding an in network physician, Press 2. For Appeals & Grievances, Press 3. For Physician Peer Review, Press 4. If you know your party’s extension, please enter now. For all other calls, press 9 and a member of your Bright Health team will be with you shortly.
How do I escalate an issue?
Please reach out to Bright’s UM team to resolve the following issues:
- Untimely decision/determinations (late reviews, unresolved requests)
- Escalate an authorization request due to a member’s condition and/or status
- Unresolved issues (NOT authorization status, which should be referenced via Availity)
Call: 1-844-990-0375
- Opt 1: PA/Inpt-Concurrent Review
- Opt 2: INN Physician
- Opt 3: A&G
- Opt 4: Peer to Peer
- Opt 5: Providers calling about members living in Oklahoma
- Opt 9: All other calls
How do I get help?
For any questions or concerns, please contact provider services at 866-239-7191 Monday - Friday 8:00am - 8:00pm local time.
How do I provide feedback?
We are continuously working to improve our experiences and solutions so if you have any feedback to share with the product team, please contact provider services at 866-239-7191 Monday - Friday 8:00am - 8:00pm local time.