RESOURCES FOR PROVIDERS
Prior Authorization Search
Access our searchable file to determine which services require prior authorization. It’s important to check this list before performing a procedure or service for your patients to avoid claim denials.
Common Ground Healthcare Cooperative works collaboratively with providers to ensure that our members receive the highest quality, most cost-effective care possible. CGHC’s partnership with Aurora Health Care and Bellin Health features integrated care systems that focus on improving the health of the community by providing the right care in the right setting at the right time.
If you are currently a provider working with us, you may be in one or both of our networks. Our Envision network, which is the only network we offer in the individual market, mainly consists of providers affiliated with the Aurora or Bellin Health Systems. In the Small Group market, we offer Envision along with an additional network, Empower, which consists of providers contracted through the Trilogy network.
If you have any questions, please contact us at 877.514.2442.
CGHC contracts with Smart Data Solutions (SDS) for facilitation of EDI claim submission and real time benefits/coverage and claim status inquiries.
Providers interested in using the Common Ground Healthcare Provider Portal for Online Claim Submission and Eligibility Verification can register with SmartData Solutions by clicking here. Should you need assistance with your claims submission or have portal questions, please contact SmartData Solutions Provider Support at 855.297.4436.
For EFT payment(s) please register with InstaMed by clicking here. InstaMed offers support to users Monday through Friday 6:00 am to 8:00 pm Central Time. Please call 215.789.3680 with your questions.
Prior Authorization requests must be received by Common Ground Healthcare Cooperative at least five (5) business days prior to the anticipated date of the service/procedure. Please note that for urgent or emergency admissions, Prior Authorization must be obtained within 48 hours of the admission or the next business day. Approval of an elective inpatient admission to a facility is required prior to the elective services being received. We will notify the member in writing of the decision regarding a determination for elective outpatient services.
If the provider determines that additional care beyond the services specified or the length of time originally authorized is medically indicated, we must be contacted to request an extension of the original authorization. The member and the provider will be notified whether the request for an extension is approved or denied.
Prior Authorization must be obtained regardless of whether Common Ground Healthcare Cooperative is the patient’s primary or secondary health insurance carrier. Prior Authorization does not guarantee coverage and/or payment if a benefit maximum has been reached or coverage has been terminated.
Prior Authorization List
- Any procedure that could be considered cosmetic
- Botox injections
- Routine care associated with Clinical trials
- Cochlear Implants
- Dental care resulting from an accident
- Dental/Anesthesia – Hospital Ambulatory Surgery Services
- Diagnostic testing including MRI, MRA, PET, CT Scans, Echocardiogram, psychological testing and neurological testing
- Durable Medical Equipment over $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a single item). Some examples include but are not limited to:
- Continuous glucose monitoring device
- CPAP machine for sleep apnea
- Insulin pump (not for supplies only)
- Feeding pump
- Transcutaneous Electronic Nerve Stimulator (TENS)
- Implantable devices, including but not limited to infusion pumps and neurostimulators
- Hospital bed(s)
- Inpatient Confinement, including Inpatient Hospice (not including observation stay which is less than two (2) midnights)
- Care or confinement levels other than Inpatient: Residential, Partial Hospitalization, Intensive Outpatient services, Skilled Nursing Facility, and Inpatient Rehabilitation Facility.
- Oral Surgery
- Prescription Drugs — As noted in the Prescription Drug Formulary, any drug requiring Prior Authorization for Step Therapy (ST) or for quantity limit (QL) must be approved by OptumRX at 855-577-6545
- Reconstructive or plastic surgery procedures, including breast reconstruction surgery following mastectomy
- Specialty Medications administered in an office or outpatient setting
- Surgery – Outpatient hospital, free standing surgical center and ambulatory surgery centers (does not include physician office procedures).
- Temporomandibular joint disorder services and procedures, including but not limited to orthognathic procedures
- Transplant evaluations, services, and procedures
Prescriptions Requiring Prior Authorization
Please submit completed prescription authorization requests via phone by calling 1.800.711.4555 or electronically through go.covermymeds.com/OptumRx.
To review a list of short acting opioids click here.
NOTE: When submitting an authorization request, it is important to use Drug Specific forms when applicable. Please use the most up-to-date forms on OptumRx’s website and be sure to include all of the relevant information. If a submitted request is missing information the request(s) can be delayed or denied due to lack of information. Please check for the drug specific form because the use of out dated or general forms may not contain all required elements and could result in a delay or denial of the authorization request.
Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:
- Emergency Care
- Urgent Care
- Maternity care for new members in 3rd trimester of pregnancy (prior authorization is required)
- Full-time students enrolled in Institutes of Higher Learning seeking behavioral health or substance abuse disorder treatment outside of CGHC’s services area but within the state of Wisconsin.
* Please note follow-up care is not covered at out-of-network facilities.
General Prescription Prior Authorization Form
(to be used only when a drug-specific form is not available from OptumRx)
Envision Individual ID Card
Envision Small Group ID Card
Empower Small Group ID Card
ID Number Definitions
Common Ground Healthcare Cooperative mails health plan ID cards to all CGHC Members. Each card contains information on the Member’s assigned network (Envision or Empower), the date benefits were first available to the Member and the Member’s out-of-pocket payment indicators. When checking eligibility, Providers should confirm the Member’s network assignment at the time of patient registration.
- Beginning with leading zeros – On Exchange Individual Member
- Beginning with I (capital letter i) – Off Exchange Individual Member
- Beginning with S (capital letter s ) – Off Exchange Small Group Member
- Beginning with 1 (number one ) – SHOP Small Group Member