If you purchase your health insurance directly with CGHC (not on Healthcare.gov), then please mail or email us your address change information using this form.

email: info@commongroundhealthcare.org
mail: 120 Bishop’s Way, Suite 150, Brookfield, WI 53005

If you feel you have made an over payment and are owed a refund, please contact our Member Services department at 877.514.2442. We do our best to issue refunds  within 30 days of any over payment.

If you are NOT receiving a tax credit for the purchase of health insurance, we will give you 31 days to bring your account up to date. During this time, you are responsible for the cost of any health claims and we will not pay for your prescriptions at the pharmacy until you bring your account fully up to date.

If you are receiving a tax credit for purchase of health insurance, we will continue paying for covered claims in the first 30 days of your grace period. We will begin to “pend” coverage of your healthcare claims after the first 30 days. Pending your claims means that we will hold on to them without paying them until you bring your account fully up to date. We will also let your doctor know you are in your grace period. You are responsible for your health claims after 30 days and we will not pay for your prescriptions at the pharmacy until you bring your account fully up to date. When your account is 90 days past due, your plan will be terminated retroactive to the date you last paid premium through.

Remember, to end a grace period you must pay all past due balances as of the day your payment processes so your account is fully up to date. Partial payment will not extend the grace period.

Click here to learn more about Health Savings Account health plans.

Purchasing an HSA eligible health plan is just the first step in gaining tax-advantages when paying for medical expenses. The second step is to open an HSA account at your bank or credit union. Any money you put into your HSA account can be used to pay for deductibles, copays and out-of-pocket healthcare costs. The money deposited into an HSA account is not taxed at the time of deposit or upon withdrawal as long as you spend it on qualified medical expenses. It’s all documented on your tax return. Best of all, the money is yours to keep and rolls over from year to year. Click here to learn more.

In addition, some of the services we cover require prior authorization. A prior authorization is a written form completed by your physician requesting approval for you to seek certain services.  A prior authorization request must be approved by CGHC prior to services being received in order for them to be covered by your plan. The Prior Authorization request must be received at least five business days prior to the anticipated date of your service or procedure. Please note that for urgent or emergency admissions, prior authorization must be obtained within 24 hours of the admission or the next business day. When circumstances such as these occur, please call 877-779-7598 as soon as possible and submit a request for an expedited Prior Authorization review of an urgent claim. A decision will be made within 24 hours of receiving the requested information.

If you fail to obtain written prior authorization for designated services, eligible charges will be reduced by 50% up to a maximum penalty of $1500. The 50% penalty will apply first, before deductibles, coinsurance, or any other plan payment or action. The 50% penalty does not apply toward your maximum out-of-pocket. To obtain prior authorization, call 1-877-779-7598. This call starts the utilization review process.

Click here to learn more and download a list of services requiring prior authorization.

Click here to download a list of prescription drugs requiring prior authorization.

Pharmacy or medication denials are subject to similar appeal steps and rights described on these pages. Members can submit this type of appeal to: OptumRx, Prior Authorization Department, PO Box 5252, Lisle, IL 60532. This same procedure applies to requests for exceptions to gain access to medications not listed on our formulary. Or, you can call OptumRx at 855.577.6545.

If you did not enroll during open enrollment, you can only enroll if you’ve had a significant life event that qualifies you for a special enrollment period. Events may include losing health coverage involuntarily, getting married, having a baby or adopting a child, losing a dependent, gaining citizenship, moving your residence, divorcing your spouse or having a change in income. To find out if you are eligible for a special enrollment period, call our sales department at 855.494.2667. Don’t delay because most special enrollment periods are only available for 60 days after the life event occurs.

A broker will continue to work with you after you have enrolled in a health plan. He or she will help you with claims or billing questions and each year at renewal time they will meet with you to explain any new options. To find a broker please call our Sales department at 855.494.2667. A Sales team member will provide a list of independent brokers in your area.

If you enrolled between November 1st and December 15th as part of the open enrollment period, your health insurance coverage begins on January 1st. You will not be able to enroll in coverage for the following year after December 15th unless you qualify for a special enrollment period.

As long as you have enrolled and paid your premium, you are covered as of your effective date even if you haven’t received your member packet and ID card. You can always call us at 877.514.2442 for assistance if you need it.

In addition, people get older every year. All insurance companies charge more the older you get, so this increase will always be a part of your insurance renewal. If you get a tax credit, this can also change from year to year and impact your share of your premium.

One thing you can depend on is that Common Ground Healthcare Cooperative will set its premiums responsibly and fairly to ensure premiums cover our costs, and that we have a sustainable cooperative in the future for our members. We do not operate for profit, so that will never be part of the consideration, and our rates will always be approved by our member-governed Board of Directors based on the best information available to us at the time of our rate filing.

Click here to learn more about how to keep your out-of-pocket healthcare costs down.

Emergency care means that you have a serious of life threatening condition that needs immediate attention. A medically necessary emergency care visit will apply to your in-network benefits including deductibles, coinsurance and copayments. When you are traveling and there is an emergency you should always go to the nearest emergency room. However, you may have to make additional payments if the out-of-network provider bills you for the difference between what they charge and our maximum allowable fee (or appropriate payment amount) for the service. Please understand that once you are no longer in need of emergency care, you will need to transition to an in-network facility for follow-up care for these services to be applied to your benefits.

Please understand even if you visit an out-of-network provider for (a) an emergency or (b) urgent care visit outside of our service coverage area or (c) in an approved referral situation, you could still be balance billed for the service. Balance billing occurs if the provider charges you the difference of your billed charges and the maximum allowable amount CGHC pays toward the service. Our maximum allowable fee is based on the amount other payers pay for the service.

In this case, an EPO referral is a form that your in-network provider must complete before you can receive out-of-network services. The EPO referral form is submitted to CGHC for review and both you (the patient) and the out-of-network provider will receive written confirmation of approval or denial of the requested services. Services received without an approved EPO referral will be denied and the payment will be the responsibility of the CGHC member. A referral is not required for urgent or emergency services.

It is important to note that a referral is separate from a prior authorization. An EPO referral is a review of network, and the prior authorization process reviews the treatment to ensure it is medically necessary. To view the list of services that require prior authorization please review the Certificate of Coverage at CGCares.org/Certificate.

Even though it is not a requirement, it is always a good idea to find a primary care physician who can help you navigate the health care system should you ever need it. We recommend that you receive your preventive care services from a primary care doctor that practices general, internal, family and geriatric medicine, including some pediatricians and OB/GYNs.

Small group plans will remain Preferred Provider Organization (PPO) plans. For group plans, the are deductibles and maximum out of pockets (or moops) are two times the in-network rate. Typically, your coinsurance rate is higher out of network.

Because we don’t have a contract with out-of-network providers, we have a maximum allowed amount that we will pay toward out-of-network care. If the doctor’s charge is higher than our maximum allowed amount, the doctor (or facility) could decide to bill you for the difference. This is called “balance billing.”  While we can and do prohibit balance billing from occurring with our in-network providers, we cannot stop it from happening if you use an out of network provider.

Please know that in a true emergency situation, we will pay for emergency care at the maximum allowed amount and it will be applied to your in-network copays, deductibles, coinsurance and MOOP if applicable. Once again, you should be aware that you may be balanced billed for out-of-network emergency services.

Click here to learn more about how to keep your out-of-pocket healthcare costs down.

If for some reason your provider fails to submit claims for you, please submit an itemized bill and receipt within 90 days of the last day on which you received services. No payment will be made on any claim that we receive more than one year after the last day on which you received services. Claims should be itemized and state the provider of the service, diagnosis, date of service, services provided, and amount charged for the services. If you have questions, please contact us at 877.514.2442.

For pharmacy claims, please click here and complete our pharmacy claim form.

For medical claims, if you are an individual or small group member and enrolled in one of our Envision plans, please send your itemized bill and receipt to:

Common Ground Healthcare Cooperative, Attn: Claims
PO Box 1630
Brookfield, WI 53008-1630

If you are enrolled in one of our Empower (Trilogy) small group plans, Submit Claims to:

Trilogy
CGHC Claims
PO Box 1171
Milwaukee, WI  53201

If you have questions about any decision we make regarding coverage of medical or pharmacy treatment, you can call us at 877.514.2442. If you do not agree with any part of the decision we made on your claim, you can file an appeal within 180 days, but not later than 3 years from the date found on this notification. Appeals must be sent to Common Ground Healthcare Cooperative (“CGHC”) Member Appeals and Grievances, P.O. Box 1630, Brookfield, WI 53008-1630. Your complaint will be reviewed by the Common Ground Healthcare Cooperative Grievance Committee and a decision will be issued within 30 days of receipt of your appeal, unless additional time is requested. You have the right to attend the Committee meeting by telephone, in person, or you may send an authorized representative in your place. You should provide all information you want considered with your appeal. Complete details regarding filing an appeal can be found in your Certificate of Coverage/policy.

Pharmacy or medication denials are subject to similar appeal steps and rights described on these pages. Members can submit this type of appeal to: OptumRx, Prior Authorization Department, PO Box 5252, Lisle, IL 60532. This same procedure applies to requests for exceptions to gain access to medications not listed on our formulary. Or, you can call OptumRx at 855.577.6545.

You have the right to pursue an independent external review if the denial of your claim is based on medical judgment (for example, medical necessity, experimental and investigational treatment, and appropriateness of health care setting). In most cases, you must go through CGHC’s internal grievance procedure first and you must file for the review with 4 months after the date you receive the CGHC decision. External reviews are conducted by the federal Department of Health and Human Services (“HHS”) through the MAXIMUS Federal Services process. Requests for review must be made in writing to: HHS Federal Review Request, MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534, or fax to 888.866.6190.

You may request an expedited review if you believe the time period for resolving your appeal will result in jeopardizing your health. In urgent situations, the internal review process can be done at the same time as the expedited review process. The expedited process will produce a binding result within 72 hours. To request an expedited review, in addition to the methods listed above, you can also call 888.866.6205.

You may also contact the Wisconsin Office of the Commissioner of Insurance for questions at 608.266.0103/toll free 800.236.8517 or send an email to ocicomplaints@wisconsin.gov. Complaints can be mailed to the following address: Office of the Commissioner of Insurance, Complaints Department, P.O. Box 7873, Madison, WI 53707-7873. Complaints may be faxed to 608.264.8155.

If your plan is employer-sponsored and governed by ERISA, you may contact the Employee Benefits Security Administration at 866.444.3272 or askebsa.dol.gov. You may file a civil action under section 502(2) of the Employee Retirement Income Security Act (ERISA) once you exhaust the grievance procedure.

If you or your family members have other insurance coverage that provides benefits that are the same or similar to this plan, we will coordinate your CGHC benefits with your other coverage. Generally, this includes other group insurance coverage and Medicare benefits.

• You become retroactively eligible for Medicaid or Medicare and request that we retroactively terminate your coverage, or
• The federal Marketplace retroactively terminates your coverage, or
• We discover after payment that you have other coverage that requires coordination of benefits, or
• We discover after payment that your injury is work related and therefore subject to workers’ compensation coverage, or
• We discover information that makes you ineligible for CGHC coverage.

To avoid any instance of retroactive denials:

• Provide full and honest answers on your insurance application;
• Notify the marketplace and/or CGHC of any changes in address or other life changes;
• Be sure to document when injuries are work-related;
• Pay your premiums on time;
• Provide documentation to the Marketplace as requested and understand the amount of your advanced premium tax credits;