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Attorney general’s probe leads to changes at Univera parent

The Rochester-based parent of Univera Healthcare has agreed to change how it handles requests from its members for treatment of substance abuse, eating disorders and other behavioral health issues following an investigation by the state Attorney General’s Office.

The settlement with Excellus BlueCross BlueShield, the largest health plan in upstate New York with 1.5 million members, is the fifth agreement the office of Attorney General Eric T. Schneiderman has reached as part of an ongoing effort to enforce federal and state mental health parity laws that require insurers to provide equal coverage, with the same costs and limitations, to mental health patients as is provided to patients with general medical problems.

The settlement announced Wednesday requires Excellus to cover residential treatment for behavioral health conditions and to reform its processes for weighing behavioral health treatment claims.

Excellus also must provide notice of a new right to appeal to 3,300 members whose requests for inpatient rehabilitation for substance use disorders and residential treatment for eating disorders were denied by the insurer between 2011 and 2014. The Attorney General’s Office put the value of the company’s denial of the requests at $9 million. Excellus also agreed to pay $500,000 to cover the cost of the probe but neither admitted nor denied wrongdoing.

The office said its investigation found that many denials by Excellus for inpatient substance use disorder rehabilitation stemmed from the company’s requirement that members fail outpatient treatment a number of times before accessing inpatient care. That requirement goes against state guidelines and isn’t applied to medical care, according to the statement from the office, which said some of the denials “appear arbitrary and wrongly decided.”

Univera, which has offices in Amherst, couldn’t break out how many of its members are affected by the settlement terms.

“We remain fully committed to providing our members with the information and resources to secure coverage for medically necessary behavioral health care,” Excellus said in a statement.

The four companies that previously agreed to settle with the attorney general are Cigna, MVP Health Care, EmblemHealth and ValueOptions, the behavioral health vendor for MVP and Emblem.