Frequently Asked Questions

Learn more about your rights and protections against surprise medical bills in this NoticeOpen a pdf.

If you believe you have received a surprise bill, please complete a Surprise Bill Certification Form and submit a copy to your provider and to the Health Plan. A completed form directs the provider to seek payment for the service from the Health Plan (your “assignment”). Once you have submitted the form to the Health Plan, no other action is required on your part. The Health Plan will review your inquiry to ensure that the bill in question meets the New York State definition of a surprise bill and will work with your provider regarding the payment.

Surprise Bill Certification Form

Do not pay any bills received from your provider while a surprise bill is being evaluated. Please contact us at the number listed on your member card if you receive any additional bills.

The Surprise Bill Certification Form is reviewed by Customer Care.

If the 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 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.

Yes. You can submit completed Surprise Bill Certification Forms from the member web via secure email. Use the Send to Us Electronically link under Submit a Claim.

Surprise Bills subject to the Federal Mandate

Providers can submit an open negotiation form. The negotiation period must be open for 30 days. For unresolved negotiations, the provider can submit an Independent Dispute Resolution (IDR) via the IDRE portal. Visit the Federal No Surprise Bill website for more information about submitting an IDR request.

Surprise Bills subject to the New York State Mandate

Members or providers can initiate a dispute request via the IDRE portal. Visit the New York State Surprise Bill website for more information about submitting an IDR request.

For your convenience, we have compiled examples of Out-of-Network Costs on our website. Please note: Medicare cost information may be found at CMS.gov fee schedule search tool.

Univera Access is a point-of-service program offered by Univera for most of our health coverage plans.

With Univera Access, you may obtain covered services from participating or non- participating providers, without a referral from your primary care physician (PCP). However, you will pay higher out-of-pocket costs than you would through referral. These costs may include higher copayments, coinsurance, and a deductible.

Some employers groups have elected not to offer Univera Access as part of their employee benefit plan. If you are eligible to receive Univera Access benefits, it will say so on your Member Card.

You may apply your Univera Access coverage to most medical services covered under your Univera Subscriber Agreement, but there are some exceptions. The services that are not covered are:

• Annual Physical Exams
• Eye Exams
• Hearing Tests
• Infertility Treatment
• Mental Health Treatment
• Outpatient Chemical Dependency Treatment

To obtain the maximum Univera Access benefit on certain services, you must receive pre-certification by calling Univera at (866) 878-2169. The services that must be pre-certified include:

• Outpatient Chemical Dependency Treatment
• Home Health Care
• Non-Emergency Hospitalization
• Outpatient Rehab (including Physical, Occupational, and Speech Therapy)
• Surgical Procedures
• Organ Transplants
• Hospice Care
• Durable Medical Equipment (if covered under your Subscriber Agreement)
• Inpatient Services in a Skilled Nursing Facility

If you fail to pre-certify these services, Univera will reduce its payment by 50%.

To obtain reimbursement for services covered by Univera Access call Customer Service at (716) 857-4448 or (800) 337-3338.

For complete information on this benefit, see the Univera Access Member Handbook at the back of your Univera Member Handbook. If you have additional questions, please call Customer Service at (716) 857-4448 or (800) 337-3338.

• Information regarding your benefits and coverage, claims and options to pay your premium bill are available online.
• Contact us at the phone number on your member card for personalized care.

At this time, electronic methods are preferred over mail.

1. Please utilize the appropriate form and attach to ensure proper handling. Refer to the Print FormsPrint Forms page for a downloadable PDF.
2. Go online to Email UsEmail Us
3. Select "Submit Other Documentation" to electronically submit your correspondenceelectronically submit your correspondence (Login required), such as:
   • Grievance/Appeal
   • HIPAA Authorization
   • Medical Records
   • Membership/Enrollment Application or Documentation
   • Other Letter/Correspondence

• Please limit submissions to common file types: PDF, Word, TIFF, JPG, PNG.
• Please allow up to 72 hours for a reply. Note: The 72-hour time-frame does not include the time required to process your document.

If you are unable to submit your documentation electronically, you may continue to submit your documentation via mail to the address on the back of your member card. Please note, there may be significant delays with the processing of documents received by mail at this time.

1. Go online to Email UsEmail Us.
2. Select "Submit A Claim" to complete a claim form and "Send to Us Electronically".

If you are unable to submit your documentation electronically, you may continue to submit your documentation via mail to the address on the back of your member card. Please note, there may be significant delays with the processing of documents received by mail at this time.

If you have a non-life threatening condition (e.g., sore throat, cold/flu symptoms, or ankle sprain) we encourage you to obtain care at one of the many Urgent Care Centers in your area.

Visit our Find a Doctor, Provider or Facility page to find an Urgent Care Center near you.

If you have an emergency medical condition, you should go directly to the nearest emergency room. An emergency medical condition is defined as a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in placing the health of the person in serious jeopardy, or in the case of behavioral health, placing the health of others in serious jeopardy; or serious impairment to a bodily function; or serious dysfunction of any bodily organ or part; or serious disfigurement. Some examples include severe chest pain, poisoning or unconsciousness.

Most managed care plan members must have a referral from their PCP prior to seeking emergency room care if the condition does not appear to be for an emergency medical condition. If you receive treatment for an emergency medical condition at the emergency room, be sure to notify your PCP within 24 hours to arrange for follow-up visits and continuing care.

With Univera Healthcare, there's no need to worry about your coverage if you get sick or injured while traveling. We've partnered with MultiPlan to provide you with a robust, nationwide provider network. Follow this link to search for a provider.

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 directory to find a FLRx participating pharmacy.

A PCP is a physician whose principal medical specialty is in family practice, internal medicine, OB/GYN, general practice or pediatrics. Your PCP is your partner in managing and coordinating your health care services. He or she works with a team of health care professionals, which may include physician assistants (PAs) and nurse practitioners (NPs), to provide your treatment. In a managed care plan, most care is provided or arranged by a participating PCP.

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.

Our Find A Doctor online tool is designed to help you connect with any doctor participating in our network, including Primary Care Physicians.

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.

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.

We can’t tell you whom to select, but we do offer tools to help you decide which practitioner is right for you.

Our online Find a Doctor feature includes participating health care professionals’ names, addresses and driving directions, specialties, office hours, and much more.

Almost all of the physicians in the area participate with us, so you have a large network from which to choose.

We encourage our female members to select a provider specializing in obstetrics/gynecology as well as a PCP. While a PCP can handle most health care needs, there may be situations where the specialized knowledge of an OB/GYN provider is required.

You won’t need a referral from your PCP to see a participating OB/GYN for covered OB/GYN care, including routine annual exams, prenatal care, or mammograms.

You may or may not need a referral from your PCP in order to obtain services from a specialist or other provider. 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 obtain a referral from your PCP.

If you are in an ongoing course of treatment when your doctor leaves your insurance plan, then you may be able to continue to receive covered services for the ongoing treatment from your doctor for up to 90 days from the date your doctor’s contractual obligation to provide services to you terminates. If you are pregnant and in your second or third trimester, you may be able to continue care with your doctor through delivery and any postpartum care directly related to the delivery.

In order for you to continue to receive covered services for up to 90 days or through a pregnancy with your doctor, the doctor must agree to accept as payment the negotiated fee that was in effect just prior to his/her leaving. Your doctor must also agree to provide us necessary medical information related to your care and adhere to our policies and procedures, including those for assuring quality of care, obtaining preauthorization, authorizations, and a treatment plan approved by us. If your doctor agrees to these conditions, you will receive the covered services as if they were being provided by a participating provider. You will be responsible only for any applicable in-network cost-sharing. Please note that if your doctor was terminated by us due to fraud, imminent harm to patients or final disciplinary action by a state board or agency that impairs the doctor’s ability to practice, continued treatment with that doctor is not available.

Follow this link to Order a Member Card Online. You will be prompted to log in.

We offer a variety of direct payment policies (when a member purchases coverage from us directly, not through an employer or group). We have policies for families, children, full-time students, seniors, and for people on low or fixed incomes.

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.

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.

Our plans have a process for reviewing health care services to ensure that they are evidence based, medically necessary, and being performed at the right level of care by qualified professionals. This process is called utilization management (UM) and it is conducted by licensed health care professionals and practitioners.

UM decision-making is based solely upon the application of nationally recognized clinical criteria and transparent corporate medical policies. We do not, in any way, encourage or reward UM decision makers for denials of coverage or limits on access to care.

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

  Residents of New York state can learn about the eligibility requirements, benefits and services of Medicare plans in the site.
  Phone - 1-800-342-9871
  Website - www.aging.ny.gov

• 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

• Office of Addiction Services and Supports (OASAS)

  The OASAS HOPEline offers help 24 hours/7 days/365 days a year for alcoholism, drug use 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 Use 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

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 * :

* If requesting by email or mail, please provide Your Name, Address, City/State/ZIP.

You have the right to:

• Receive all the benefits to which you are entitled under your contract;

• Receive quality health care through your providers in a timely manner and medically appropriate setting;

• Considerate, courteous and respectful care;

• Be treated with respect and recognition of your dignity and right to privacy.

• Information about services, staff, hours of operation and your benefits, including access to routine services as well as after-hours and emergency services, and members' rights and responsibilities;

• Participate in decision-making with your physician about your health care;

• Obtain complete, current information concerning a diagnosis, treatment and prognosis from a provider in terms that you can reasonably be expected to understand;

• Refuse treatment as allowed by law, and be informed by your physician of the medical consequences;

• Refuse to participate in research;

• Confidentiality of medical records and information, with the authority to approve or refuse the re-disclosure by us of such information, to the extent protected by law;

• Receive all information needed to give informed consent for any procedure or treatment;

• Access to your medical records as permitted by New York State law;

• Express concerns and complaints about the care and services provided by physicians and other providers, and have us investigate and respond to these concerns and complaints;

• Candid discussion of appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage;

• Care and treatment without regard to age, race, color, sex or sexual orientation, religion, marital status, national origin, economic status or source of payment;

• Voice complaints or appeals and recommend changes in benefits and services to staff, administration and/or the New York State Insurance Department or Department of Health, without fear of reprisal;

• Formulate advance directives regarding your care. To obtain a Health Care Proxy form, contact us;

• Contact one of our service departments to obtain the names, qualifications and titles of providers who are responsible for your care;

• All information about your health plan, its services and its providers and procedures.

• To make recommendations regarding the organization's members' rights and responsibilities.

You have the responsibility to:

• Be an active partner in the effort to promote and restore health by:

  • openly sharing information about your symptoms and health history with your physician;

  • listening;

  • asking questions;

  • becoming informed about your diagnosis, recommended treatment and anticipated or possible outcomes;

  • following the plans of care you have agreed to (such as taking medicine and making and keeping appointments);

  • returning for further care, if any problem fails to improve; and

  • accepting responsibility for the outcomes of your decisions.

• Participate in understanding their health problems ad developing mutually agreed upon treatment goals.

• Have all care provided, arranged or authorized by your primary care physician (PCP);

• Inform your PCP if there are changes in your health status;

• Obtain services authorized by your PCP;

• Share with your PCP any concerns about the medical care or services that your receive;

• Permit us to review your medical records in order to comply with federal, state and local government regulations regarding quality assurance, and to verify the nature of services provided;

• Respect time set aside for your appointments with providers and give as much notice as possible when an appointment must be rescheduled or cancelled;

• Understand that emergencies arise for your providers and that your appointments may be unavoidably delayed as a result;

• Respect staff and providers;

• Follow the instructions and guidelines given by your providers;

• Show your Member card and pay your visit fees to the provider at the time the service is rendered;

• Become informed about our policies and procedures, as well as the office policies and procedures of your providers, so that you can make the best use of the services that are available under your contract;

• Abide by the conditions set forth in your contract.

Mental Health benefits are available under most programs for both inpatient and outpatient mental health treatment. Inpatient mental health is hospital-based treatment. Many programs require that a member, physician or hospital contact the health plan or plan administrator to inform them of an admission. There typically are a limited number of days available for inpatient treatment in a calendar year.

Outpatient mental health benefits are for counseling for mental health problems. Some programs do not have coverage for outpatient mental health treatment. Those that do provide coverage often have a limit on the number of sessions.

Your health programs may require a primary care physician referral. Whether or not your program requires a referral, it is a good idea to discuss your concerns with your primary care physician who may be able to assist in selecting a mental health specialist.

When Univera Healthcare is responsible for the design of your Plan, reviews are performed and certified with the New York State Department of Financial Services to ensure compliance with mental health parity laws. To learn about specifics, refer to Mental Health Parity Member Disclosure.

Chemical Dependency benefits are for the treatment of drug and/or alcohol problems. Most often these services are provided in facilities that are licensed by the Office of Alcohol and Substance Use and provide individual, group and family counseling. Programs that provide this benefit often have a limited number of sessions.

Some health programs provide a limited number of inpatient chemical dependency rehabilitation days. This is when you or a family member requires medically necessary treatment in a facility that provides 24-hour care.

Some plans require you to obtain treatment from participating providers in your area. Other plans may not have this requirement, but you may need to get a referral or pay a higher copay for out of area treatment. Your plan will have information on this and the type of coverage you have. If you still have questions, you should contact the Customer Service department at the telephone number on your member card.

Prior to your care, you or your provider should contact Customer Service to see what the benefits and prior authorization requirements are for your coverage. If it is an emergency situation, there is no referral required before seeking care.

If you disagree with a decision made by us to deny a requested service, you may contact Customer Service and a representative will be glad to assist you.

All information regarding your care and treatment is confidential and protected by law. You will be asked by your provider to sign a release of information. This will allow your Mental Health or Chemical Dependency specialist to share information with your Primary Care Physician concerning your treatment plan and medical condition.

1. Contact your physician before you enter treatment, unless it is an emergency. Your physician may want to meet with you to evaluate and discuss the appropriate care for you.

2. Select a participating mental health or chemical dependency specialist, with the help of your physician.

3. Check your coverage information or call Customer Services to see what benefits are available to you and if prior authorization is required.

4. Pay all co-payments required under your program.

5. Keep scheduled appointments. Providers have the right to charge you for a missed appointment if that is their standard office policy.

We will not provide benefits for any service or treatment that does not meet the guidelines for the diagnosis of your condition. If you need additional information, please contact Customer Service at the telephone number listed on your member card.

New York State - Mental Health and Chemical Dependency Resources

If your mental health or chemical dependency benefits have exhausted, you may call one of the agencies below for assistance in obtaining necessary care.

Office of Addiction Services and Supports (OASAS) 
The OASAS HOPEline offers help 24 hours/7 days/365 days a year for alcoholism, drug use and problem gambling. All calls are toll-free, anonymous and confidential.
Phone - 1-877-846-7369
Website - www.oasas.ny.gov/hopeline/

SAMHSA - an Agency of the U.S. Department of Health & Human Services
The Substance Use 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

Note: This information is not intended to provide medical advice or to take the place of medical care, nor can we guarantee that all requests for authorization will be granted. Coverage is limited to the terms of your health care program. Any questions you have should be brought to the attention of your physician.

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.

Follow this link to enter or update your PHI authorizations online or to read our Privacy Policy.

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.

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.