UNDERSTANDING PRIOR AUTHORIZATION
It’s important to note there are certain medical services or provider visits that will require prior authorization by Common Ground Healthcare Cooperative. We require these authorizations so our Medical Affairs team can review the medical necessity of the recommended service or visit and make sure you are getting appropriate care. Medically urgent authorizations, as determined by your physician, are handled as a priority. Keep in mind, a prior authorization can only be obtained for services that are covered under your plan benefits.
Network Providers are responsible for obtaining Prior Authorization before they provide these services to you. Ultimately it is your responsibility to ensure Prior Authorization was obtained. Before receiving these services from a Network Provider, you may want to contact Us to verify that the Hospital, Physician and other providers are Network Providers and that they have obtained the required Prior Authorization. If you choose to receive covered health services from a non-network provider, you are responsible for obtaining Prior Authorization before you receive these services.
COVERED HEALTH SERVICES WHICH REQUIRE PRIOR AUTHORIZATION
The Prior Authorization request must be received by us at least 15 business days prior to the anticipated date of your service/procedure. Please note that urgent or emergency admissions, Prior Authorization must be obtained within 24 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. Please note that a verbal request for Prior Authorization does not guarantee approval. We will notify you in writing of the decision regarding a determination for elective outpatient services. If your 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. You and your 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 your 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.