Prior Authorization

We are committed to helping you access safe and effective care. To accomplish this, we use prior authorization, which is a system that ensures resources are used appropriately.

What is prior authorization?

Some treatments, medications, and procedures may require approval from Univera Healthcare before they are covered. This process is called prior authorization which ensures safe, effective, and medically necessary treatment through the promotion of evidence-based care. Prior authorization ensures every health care dollar is spent wisely prioritizing patient outcomes. Not all contracts require prior authorization, and not all contracts offer the same benefits. If you are unsure if your contract requires prior authorization or if your contract has a specific benefit, please contact the Customer Care number on the back of your member card for assistance.

Component Title: Our responsibility to your care - Hub Section

Our responsibility to your care

As your local, non-profit health plan, prior authorization decisions at Univera Healthcare are made by local doctors, nurses and other clinically qualified experts who are guided by nationwide best practices for care and what has proven successful for members in the past. Here are the steps we are taking for a seamless and transparent process:

Continuously evaluating the need for prior authorization and eliminating prior authorization requirements for treatments and procedures when appropriate
Speeding up the process through instant provider notifications, fewer steps, and faster turnaround times
If after review, a request for services is not determined to meet policy criteria, we provide personalized support including insight into what caused the request to not be approved, guidance on navigating the appeals process, and help understanding what would be covered

Component Title: Member and provider rights - Hub Section

Member and provider rights

We encourage any member or provider who is not satisfied with a decision to contact Customer Care. We have a robust appeals process in place, as governed by state and federal laws
Providers can request to speak with our on-staff medical directors and physicians to discuss a member’s situation and request for services
It is always recommended that members contact Customer Care with concerns as soon as possible by calling the number of the back of their member card. We will make every attempt to resolve issues quickly over the phone

Frequently asked questions

How do I know if prior authorization is required?

Univera Healthcare is continuously reviewing prior authorization requirements to ensure prior authorization is only required when necessary.

To determine if it is required, review the prior authorization procedure code list. You will need to ask your provider for the service/procedure code for your requested service.

Who is responsible for notifying Univera Healthcare about the need for a prior authorization?

In most cases, your doctor or provider will submit the prior authorization request for you. For some PPO plans, you may be responsible for notifying us for certain services. If your provider is responsible for requesting your prior authorization, and you are not sure that the request has been made, please contact your provider. If you have a plan that requires you to start the process, please contact Customer Care by calling the number on the back of your member card.

What happens when a service or treatment requires prior authorization, but it was not requested?

Always check with your doctor or provider to see if they have initiated the prior authorization process. Without the required prior authorization, Univera Healthcare may not cover the requested service.

What should I do if I am having difficulty reviewing the prior authorization procedure code list?

For an easier experience, you can search for a specific term or procedure code within the document by pressing Ctrl+F (or Cmd+F on Mac) to open the Find box. If you have questions about what services require prior authorization, please call the phone number listed on the back of your member card.

Where can I review medical policies?

Browse our medical policies for thorough descriptions and guidelines. These policies are updated frequently.

Are there any resources providers can use to determine if prior authorization is required?

Not all contracts require prior authorization or offer the same benefits. If a provider is unsure if the service requires prior authorization or if the member’s contract has a specific benefit, we recommend using the provider prior authorization lookup tool. The same list of services is available in the prior authorization procedure code list but requires manual review.

For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: cardiac services (imaging and devices), radiology/imagining, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.

For Medicaid Managed Care (MMC) or HARP member, please review the eMedNY website for benefit coverage of specific codes prior to submitting a prior authorization request.