RESOURCES FOR PROVIDERS
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Prior Authorization Search
If you are currently a provider working with us, you a part of our Envision network, which is offered for both individual and small group coverage. The Envision Network consists of providers affiliated with Aurora Health Care, Bellin Health Systems, ThedaCare, Door County Medical Centers, Children’s Hospital and Health System, and St. Joseph Hospital – Milwaukee Campus.
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 Information
CGHC follows NCQA guidelines in reviewing prior authorization requests and making determinations, but it is important that providers submit Prior Authorizations timely to ensure enough lead time for a member’s services.
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.
For resources to help you navigate prior authorizations for CGHC members, use these materials:
Prescriptions Requiring Prior Authorization
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.
Step Therapy Processes and Requirements
- Food and Drug Administration (FDA) information
- Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-analyses, review articles, comparative effectiveness research, evidence-based medicine reviews, healthcare technology assessments, and pharmacoeconomic and outcomes research
- Treatment guidelines, practice parameters, policy statements, consensus statements created/endorsed by reputable governmental, medical, and/or pharmacy organizations
- Pharmaceutical, device, and/or biotech company information
- Medical and pharmacy tertiary resources, including those recognized by CMS
- Relevant and reputable medical and pharmacy textbooks and or websites
*These are specific to health plans and insurers utilizing our Select and Premium drug lists only. Your patient’s prescription drug benefits may be covered under his/her plan-specific formulary for which these guidelines may not apply. We recommend you speak with your patient regarding Prescription drug benefit coverage under his/her health insurance plan.
**OptumRx’s Senior Medical Director provides ongoing evaluation and quality assessment of the OptumRx UM Program.
OptumRx Prior Authorization and Exception Request Procedures
Submitting an electronic prior authorization (ePA) request to OptumRx ePA is a secure and easy method for submitting, managing, tracking PAs, step therapy and non-formulary exception requests. It enables a faster turnaround time of
coverage determinations for most PA types and reasons.
Login to your preferred web-based portal account and select “New Request” within your Dashboard to submit your PA request.
General Prescription Prior Authorization Form
(to be used only when a drug-specific form is not available from OptumRx)
ID Number Definitions
Common Ground Healthcare Cooperative mails health plan ID cards to all CGHC Members. Each card contains information on the Envision network, 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