Univera Healthcare logo
Login | Register | Forgot Username | Forgot Password
Clinical Editing Policies
Fee Schedules
Request an Adjustment
Sign Up for EFT
Procedure Code Modifiers
Medical Record Submission Requirements
Medical Record Submission Requirements

Providers must submit medical records upon initial claim submission of services that are considered experimental, investigational or require medical necessity determination. Claims submitted without the records may result in the denial 'Medical record submission guidelines not followed' and members will be held harmless. In this case, you may resubmit a new claim with the necessary records.

For contractual reviews, we will continue to contact the provider by letter to request any required clinical information.  

Please submit the documentation that best provides supporting evidence for the services rendered.

View the links below for more information:

Retrospective Risk Adjustment Medical Record Requests

Medical records requests are a key part of our Health Plan's Risk Adjustment activities. Your office may receive medical records requests to support the programs listed in the chart below; and sending the records and/or allowing us to retrieve them from your office, is a condition of your participating provider agreement with our Health Plan.

In some instances, our Health Plan has data validation audits that involve the retrievel of medical records taking place concurrently. We do our best to avoid duplicative record requests; however, if you receive multiple requests for medical records, please follow the instructions provided in each request.

Our Health Plan has executed a Business Associate Agreement with our record retrievel vendors, which are independent companies, and we have implemented appropriate safeguards to ensure full compliance with all defined privacy and security provisions.

Thank you for your prompt attention to these requests and your participation.

Risk Adjustment Activities
By Line of Business
Medical Record
Starting Timeframe
Record Retrieval Vendor
(independent company from our Health Plan)
Dates of Service
August 2018 Change Healthcare Calendar Year 2017
Advantage Retrospective
Risk Adjustment Audit
August 2018 CIOX Health, LLC
(fka ArroHealth)
Calendar Year 2017
through present date
ACA Commercial
Retrospective Risk Adjustment Audit
February 2019 CIOX Health, LLC
(fka ArroHealth)
Calendar Year 2018
Retrospective Risk Adjustment Audit
April 2019 Change Healthcare Calendar Year 2018
home     news & updates     print forms     about us     fraud & abuse     glossary     accreditations   
Language Assistance and Non-Discrimination Notice

Copyright © 2019, Univera Healthcare, an Excellus company. View our Web Privacy Policy for information on how we protect your privacy. Use of this site indicates your acceptance of our Terms of Use. You will need Internet Explorer or Google Chrome to use the secure features of this site.