Page Title for page template
Frequently Asked Questions
Univera Healthcare provides a process to follow if you and/or your health care provider disagree with our decision to deny services. If the denial was based on your contract, you may file a grievance. If the denial was based on medical necessity and/or the experimental or investigational nature of the treatment, you and/or your health care provider may request a medical appeal.
Whether it's for a grievance or a medical appeal, the first step in the process is to file your concern with our Customer Service Department.
Call Customer Service at the phone number listed on your Member Card, or view our Contact UsContact Us page for a listing of phone numbers. You may also submit your grievance or request for appeal in writing. See our Contact Us page for the address of your local office.
If you would like to appoint a representative to act on your behalf, give Customer Service that person's name. At any time, you may also file a complaint with the State Department of Health, (800) 206-8125, or the State Department of Insurance, (800) 342-3736.
In the majority of cases, your health care providers will file claims to us on your behalf. That is why it is very important for you to have your Univera Healthcare member card with you at all times. If you need to file a claim yourself, follow this link to print a claim formprint a claim form in our online forms center.
Providers can submit disputes to the IDRE by submitting an application through the Department of Financial Services (DFS) portal. Members who do not complete an AOB form can submit a dispute by completing the IDR Patient Application and sending it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Yes. Providers may dispute payments from the plan for a bill through an Independent Dispute Resolution Entity. If that body rules in favor of the provider, the charge for the service could be increased, causing your cost-sharing amount to possibly increase. This occurs most frequently when your cost-share for a particular benefit is a deductible or coinsurance.
The AOB form is reviewed by Customer Care.
If the AOB form is for a claim that meets the definition of a surprise bill, the Health Plan will work with the provider to resolve the bill. If we are unable to agree on a payment, we will pay what we deem to be a reasonable amount. An adjustment amount may appear on your next Monthly Health Statement or Explanation of Benefits.
If the provider is not satisfied with our payment, he/she may submit the claim to an independent dispute resolution entity who will determine whether our payment or the provider’s charge is most reasonable. The IDRE’s determination is binding on us and the provider.
If we determine that the AOB form is for a claim that does not meet the definition of a surprise bill, we will notify you of the denial and you will be responsible for any costs not covered under your contract.
Out of Network
For your convenience, we have compiled examples of Out-of-Network Costs on our website. You may also visit Fair Health’s website (www.fairhealthconsumer.org) to estimate potential out-of-network out-of-pocket expenses. Please note: Medicare cost information may be found at CMS.gov fee schedule search tool.
If you have our prescription drug coverage and need to fill a prescription while traveling, you can use FLRx, our National Pharmacy Network. There are over 50,000 FLRx pharmacies in the United States who will electronically file your prescription claim. This means less out-of-pocket cost to you, and less hassle because there's no need to fill out paperwork. View our online pharmacy directoryonline pharmacy directory to find a FLRx participating pharmacy.
Managed care and point of service (POS) plans require you to select a PCP to provide, manage, arrange or authorize almost all the medical care you receive. Your PCP is your partner in managing and coordinating your care and will refer you to a specialist, when needed.
Check your contract or benefit booklet, talk to your employer group representative or contact us if you are unsure whether or not you need to select a PCP.
If you are currently in treatment with your PCP, we can make the change effective on the date of your request.
For our records, we may ask that you give a reason for changing your PCP. This information is optional and can be used to track patient access, quality of care and other provider trends. Follow this link to Select or Change Your Doctor Now. If you would rather speak to us directly, please contact our Customer Service department at the number listed on the back of your member card.
Eligibility, Coverage & Benefits
The Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010 requires private insurers that offer dependent coverage for children to allow young adults up to age 26 to remain on their parent’s insurance plan.
To learn more about PPACA, visit our Health Care Reform page and click on the “Resources” tab.
Contract changes may be made at any time due to a qualifying event such as a birth, death, marriage, divorce or loss of employment. If you have coverage through an employer or group, you may be able to update your policy online (if your employer or group participates in online enrollment). If you are unsure, please contact your group benefits representative. If you purchase your coverage directly from us, please call us at the number listed on your member card.
New York State Exhausted Benefit Resource Guide
If your benefits have exhausted for medical or behavioral health services, you may contact one of the agencies below for assistance in obtaining necessary care.
- New York State Partnership for Long Term Care
The New York State Partnership for Long Term Care is a unique program that combines private long term care insurance and Medicaid to help New Yorkers prepare financially for the possibility of needing nursing home or home care.
Phone - 1-866-950-7526
Website - https://nyspltc.health.ny.gov/
- CMS - State and Local Information
The Centers for Medicare & Medicaid Services (CMS) provides Medicare and Medicaid information for each state. The website includes Frequently Asked Questions and search capabilities.
Website - www.cms.gov
- New York State Office for the Aging - Medicare Links
- New York State Department of Health
The New York State Department of Health can be a useful source of consumer information. The website includes a Directory of Services and links to New York state government resources. Check your local phone directory for specific agency listings.
Website - www.health.ny.gov
- New York State Office of Alcoholism and Substance Abuse Services (OASAS)
The OASAS HOPEline offers help 24 hours/7 days/365 days a year for alcoholism, drug abuse and problem gambling. All calls are toll-free, anonymous and confidential.
Phone - 1-877-846-7369
Website - www.oasas.ny.gov/accesshelp/
- SAMHSA - an Agency of the U.S. Department of Health & Human Services
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation.
Phone - 1-877-726-4727
Website - www.samhsa.gov
NYS Guide to Health Insurers
The New York Consumer Guide to Health Insurers is available from the New York State Insurance Department. The guide provides important consumer information on the performance of health maintenance organizations (HMOs) and other insurers. You can find us in the guide under the name Univera Healthcare.
You can view this report online at www.dfs.ny.gov/consumers/health_insurance/health_insurance_complaint_rankings or use the addresses below to request a printed copy:
Email to * : Publicat@ins.state.ny.us
Mail to * :New York State Insurance Department
Attn. NY Consumer Guide to Health Insurers
Agency Building One, 5th Flr.
Albany, New York 12257
* If requesting by email or mail, please provide Your Name, Address, City/State/ZIP.
Protect Your Privacy
Under the federal Health Insurance Portability and Accountability Act (known by its acronym, HIPAA), we are required to protect any and all information that could lead anyone to identify you by your past, present and/or future medical or mental health treatment or conditions. This is also known as your protected health information (PHI).
Because of HIPAA, we cannot release any information regarding your policy, claims or benefits without your express permission.
The law does allow us to discuss your PHI with your health care providers, but only within the scope of services that they themselves are providing to you.
Yes, these regulations require that any protected health information about members or their dependents age 18 or older cannot be released, even to family members, without the member’s authorization.
If not releasing the information would put your health in danger, we are allowed to release it to those who need to know it. In these cases, we will not release more information than necessary.