Frequently Asked Questions & Member Forms

Research specific question topics through the buttons below. Otherwise, scroll down, and click on each question to open the answer. Any member forms can be found at the bottom of this page.

General Questions

What does it mean to be covered by a cooperative?

In 2012, Common Ground Healthcare Cooperative (CGHC) was founded when a group of like-minded community leaders came together with an idea. They wanted to create a different kind of health insurance that focuses on the needs of individuals, families, and small employers. The Affordable Care Act (ACA) consumer operated and oriented plan (Co-op) program offered the right opportunity.


CGHC remains true to our roots. As a nonprofit cooperative (under Wisconsin law), we exist to serve our members and give them a voice. Putting members first, pursuing better healthcare is our mission. Our member-governed Board of Directors is elected by our membership. We value member feedback and use it to improve our products and services. You can learn more about our corporate history on our website.

What does the Board of Directors do?

The CGHC Board of Directors is made up of people who buy our insurance. The entire adult membership of CGHC elects our board members. The member-governed board has the authority to approve our budget and rates (premium) and oversee our operations. You can read more about our Board of Directors on our website.

When does the annual election of the Board of Directors take place?

We begin the annual election process in January. That’s when we inform members that we are looking for nominees for the Board. Members may nominate themselves or another adult member. A committee reviews all nominations received, conducts interviews, and makes a formal recommendation to the Board by the end of March. The board then determines the slate of candidates that will appear on the ballot. The election coincides with the annual meeting so members can meet the candidates and cast their ballot in person.

Healthcare Data
How can I access and share my healthcare information and data?

CGHC is happy to provide members with easy access to their healthcare data. This can be done via a web portal or a mobile application (app). To learn more, please visit the Transparency in Coverage page of our website. (Exchange) Federally Facilitated Marketplace (FFM)
What is the relationship between Common Ground Healthcare Cooperative (CGHC) and the Health Insurance Marketplace® (Exchange)

CGHC is a nonprofit health insurance company. We offer health plans that are available on the Health Insurance Marketplace® (On-Exchange) at the government website We also offer health plans outside of (Off-Exchange). All CGHC health plans (On- and Off-Exchange) can be purchased through the CGHC website.


To enroll in an Off-Exchange health plan, the entire process is direct with CGHC.


To enroll in an On-Exchange health plan, you can start the enrollment process on the CGHC website or directly at The U.S. Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services operate the Health Insurance Marketplace® (Exchange) and its official website That’s where you can buy an On-Exchange health plan and find answers to your questions about the Affordable Care Act (ACA). We recommend that you check out the page. It’s a great place to start when you need answers about health insurance.


When you enroll in a CGHC On-Exchange health plan, your application is created on the website – even if you started on the CGHC website. CMS, via, is the keeper of your health plan application, which you can access through CGHC. They decide if you qualify for a tax credit or other help lowering your monthly premium responsibility. On a daily basis, CMS sends to each insurer the enrollment and eligibility data for the people who purchased On-Exchange health plans.


This is why CGHC Member Services says that you must contact the Health Insurance Marketplace® at 1.800.318.2596 (or login to your account on website) if you need to:


  • Get help lowering your monthly premium responsibility
  • Obtain your 1095-A tax form if you receive an advance premium tax credit (APTC)
  • Cancel your coverage (e.g., when you become eligible for other insurance coverage such as Medicare, Medicaid, or an employer plan)
Health Savings Account (HSA)
Which bank can I use with a Health Savings Account (HSA)?

You can use any bank or credit union that offers an HSA option. After purchasing an HSA-eligible health plan, simply open an HSA account at your bank or credit union. Important – CGHC does not monitor your HSA account. To learn more about HSA accounts, visit the website.

How do I know if my CGHC plan is eligible for a Health Savings Account (HSA)?

All CGHC health plans that are eligible for a health savings account will have “HSA” in the plan name. To determine if your plan is HSA eligible, login to the My Health Portal. You can view the full plan name on the Schedule of Benefits (SOB) or Summary of Benefits and Coverage (SBC).

Where can I find answers to general questions about health insurance?

At CGHC,  we want to make health insurance as easy to understand as possible. Please visit the Understanding health insurance page on our website. It includes terms such as cost share, deductible, coinsurance, copay, and out-of-pocket maximum. The website also offers a glossary, which is another great place to find answers.

Language Assistance
How can I get language assistance?

If you, or someone you are helping, have questions about Common Ground Healthcare Cooperative, you have the right to obtain help through an interpreter at no cost. To speak with us using an interpreter, call Member Services at 1-877-514-2442.


View the Language Assistance document


View the Privacy page

Member Rights
Where can I read about my rights as a CGHC member?

You can read about your rights and responsibilities as a CGHC member on our website and in your Certificate of Coverage (COC).

Why do health insurance costs keep going up?

The cost of health insurance reflects the cost of health care (hospital services, physician visits, imaging, lab tests, prescription drugs and more). When we set our premiums for the coming year, we look at the history of healthcare costs we have received and estimate the costs that we expect in the next year. We then set premiums so we can cover these costs. The challenge is that healthcare costs are constantly increasing.


To bring down health insurance costs would require bringing down the cost of healthcare. Unfortunately, there has not been much progress on that front. We encourage you to watch this 5-minute video that talks about our country’s health care system and why costs are so high.


Please be assured that as a nonprofit cooperative, we work hard every day to make coverage for our members as affordable as possible. Our rates are always approved by our member-governed Board of Directors based on the best information available to us at the time of our rate filing.

HIPAA Privacy Rule
What is the HIPAA Privacy Rule?

CGHC maintains the privacy of your health information in compliance with applicable laws and regulations (Health Insurance Portability and Accountability Act (HIPAA)). We encourage you to visit the Privacy page of our website. There you will find our Privacy Practices and other important legal notices.

Protected Health Information (PHI) Form
What is protected health information (PHI)?

The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. Learn more about protected health information at:

Can I authorize release of my protected health information (PHI) to another person?

You may authorize another person or company to receive and/or discuss your personal health information (PHI). Simply complete the Authorization to Release Protected Health Information form.

How does CGHC handle complaints?

A complaint is a verbal expression of dissatisfaction. You might be unhappy about:


  • Common Ground Healthcare Cooperative (CGHC)
  • Our contracted providers (e.g., wait time in a doctor’s office, ability to schedule appointments, or provider billing practices)
  • A vendor who provides services on our behalf


Whatever your concern, we take all complaints seriously. Please contact our Member Services Team at 1-877-514-2442 to discuss what happened. We will investigate your concerns and respond in a timely manner.

Appeal & Grievances
What is the difference between an appeal and a grievance?

An appeal is a written expression of dissatisfaction with the following types of denials:


  • A prior authorization request
  • An adverse medical decision (services determined to be experimental, investigational, or not medically necessary)


A grievance is a written expression of dissatisfaction with the following:


  • Any provision of services (the benefits covered by the plan)
  • How we process claims (CGHC claims practices)
Who can submit an appeal or grievance?

The member, or their authorized representative, can file an appeal or grievance request. An Authorized Representative (AR) is someone who is appointed by the member to file and pursue a grievance or appeal, or make an inquiry, on the member’s behalf. We need to receive a signed Authorized Representative Form (ARF) from the member for the representative to act on their behalf. Keep in mind that by allowing an AR to pursue the grievance or appeal on the member’s behalf, they are exhausting those rights under the member’s policy.

How is an appeal or grievance submitted?

All appeals and grievances follow the same process. However, the time limit differs based on the situation or medical need. You, or your authorized representative, can file an appeal or grievance request by using one of the forms on this web page. When completing the Appeal Form or the Grievance Form, please include all details of your case (name, address, phone number, prior authorization number, claim number, service or medication being requested, etc.). Be sure to provide evidence of why the service or medication is needed or why the claim should be processed differently. For example, for appeals, provide the following types of information that help to support medical need such as medical records, physician notes, journal articles, and/or clinical trial information. For grievances, provide copies of claims or bills you may have received, along with any supporting medical information listed above.


Once you complete and sign the form, send it to CGHC:


Fax: 262-754-9690 Attention Appeal & Grievance


Mail: Attention Appeal & Grievance, PO Box 1630, Brookfield, WI 53008-1630




Warning – Please keep in mind that communications sent via email over the internet, unless sent encrypted, are not necessarily secure. Although unlikely, there is a possibility that the information you include in an email can be intercepted and read by other people besides the one to whom it is addressed.


CGHC will send an acknowledgement within five (5) business days of receipt. That letter will include the date of your committee hearing. All appeals and grievances are carefully researched. We will resolve the case within thirty (30) calendar days from the date it was received unless an extension is needed. If an extension is needed, we will send you a letter explaining why we need more time. For example, when we are waiting for information from a provider. The letter will include the date we anticipate being done. After the meeting, you will receive an outcome letter telling you the decision of the committee.


If you appeal a denial of services or reduction in services that you are currently receiving, you may continue to get these services while you appeal. However, if the appeal decision is not in your favor, you may be financially responsible for the cost of the services received.

How do I request an EXPEDITED appeal or grievance (24 or 72-hour time limit) for an urgent need?

An expedited process is justified if the timeframe (30 calendar days) for a standard appeal or grievance could seriously jeopardize your life or health. This includes your ability to attain, maintain, or regain maximum functions. The decision is made based on the details included in the written request. This includes your provider’s support of the request, and/or our internal review. Follow the appeal process provided above. On the appeal or grievance form, please check the box to indicate an “Expedited Review” is needed. Be sure to explain why an expedited review is requested. We will review your request to determine whether a need for urgency exists.


If the request for expedited review is granted, we will provide a decision within:


  • 24 hours for expedited reviews involving:
    • Appeal requests that concern admission to a facility, continued stay in a facility, or healthcare services for a member who received emergency services but has not been discharged.
    • Urgent non-formulary drug exception requests that were denied during the prior authorization


  • 72 hours for expedited reviews involving:
    • Appeal requests that concern an urgent situation that doesn’t involve inpatient admission to a healthcare facility.
    • Standard non-formulary drug exception requests that were denied during the prior authorization


If the request for expedited review is denied, the standard thirty (30) calendar day review period.

General Questions

Where can I get my general questions about insurance answered?
Common Ground Healthcare Cooperative has partnered with Covering Wisconsin to bring easy to understand information to you.  This includes an explanation of terms such as deductible, coinsurance, copay and out of pocket maximums.  Please visit our resources page to learn more.
What does it mean to be covered by a cooperative?
In many ways, cooperatives behave much like any other health insurance company. We meet the same laws and regulations, and we provide medical insurance and prescription drug coverage. What makes us different is that we are a nonprofit organization that is governed by its members. We answer to our members, not corporate shareholders, so we have absolutely no motivation to raise prices simply to make more money. Our Board is made up of individuals buying our insurance, who are elected by the entire membership. The member-governed board has the authority to approve our budget, approve our rates, and oversee our operations.
How do tax credits for health insurance work?
If you are eligible for an Advanced Premium Tax Credit (APTC)  from the federal government, it means that the federal government is paying a portion of your health insurance bill every month. You will see this reflected on your monthly invoice. You can only get tax credits if you buy health insurance through, whether that is with the help of an insurance agent, Common Ground Healthcare Cooperative staff or on your own. The amount you receive is based on the income you’ve reported to the federal government on your taxes or on your health insurance application. That is why it is very important to report any changes (income, births, moves and so on) to the federal government as soon as possible, so you do not receive more or less than you should. Either way, your tax credit will be “settled up” at tax time. You can also opt out of advanced payment of the tax credit by contacting, but then you will have to pay the full amount for your health insurance.
When is my bill due? How do I pay my monthly bill (premium)?
You must pay your premium by the 25th of the month prior to coverage (for example, by May 25th for June coverage) to avoid any interruptions in your coverage. If you do not pay your bill on time, you will enter into a grace period that you cannot get out of until you pay your total balance due in full as of the date your payment processes. We have several options for payment, including online recurring payments. Click here to learn more.
How do I change my address or make other changes?

If you are receiving a tax credit for your coverage, or if you have otherwise purchased health insurance through (even through an agent or CGHC), then you are required by law to report any address or life changes (marriages, births, change of residence, etc) to We cannot update our records until the federal Marketplace ( updates its records.


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


Mail: 120 Bishop’s Way, Suite 150, Brookfield, WI 53005

What is the difference between Common Ground Healthcare Cooperative and

Many times when a member talks with the federal government-run Marketplace ( they think they are talking with us, their health insurance company. It’s important to understand we are very separate organizations, and we generally talk to each other electronically through data files. If you have a concern about the service you’ve received through, there is little we can do to influence that. But, we can help you understand how to navigate, including how we might help report errors and open up complaint tickets. Just call us at 877.514.2442 so we can explain what we can help with, versus what the federal government will need to help you with.

How does CGHC handle complaints and refund overpayments?

We maintain an internal process for the timely investigation and resolution of complaints and grievances. Members may file a complaint/grievance regarding any aspect of care or service provided to them by CGHC or our contracted providers. The internal complaint/grievance process includes steps to ensure careful and complete consideration is given to each complaint/grievance. More information about the complaint/grievance process is on our website. You may also call Member Services at 877.514.2442.


  • When a policy is terminated, if there is a credit on the account, a refund will automatically be issued to the policy subscriber. Refunds are processed within 30 days of the policy termination. They are issued via paper check made payable to the policy subscriber and sent via U.S. Postal Service mail.
  • CGHC does not issue refunds for active policies with credit balances. When premium invoices are generated, any credit on the policy is automatically applied to the invoice. This reduces the Member Responsibility (amount due) for that month’s invoice.
What if I’m late paying my bill? Is there a grace period?

Yes. If you do not pay your bill on time, we will give you a short grace period to help you catch up and keep your health insurance coverage. This is very important, because once you lose coverage for nonpayment of premiums, that coverage cannot be reinstated.  This means you are not eligible for another plan until January 1 of the following year, unless you have a qualifying life event. The length of the grace period that applies depends on whether or not you are receiving a tax credit (APTC) for the purchase of insurance through

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.

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Plans & Benefits Questions

How can I find out if my doctor is in the CGHC provider network?

To check if your doctor is in our health plan network or to find a doctor in your area, go to our provider directory. Click here to search our online provider directory offered to all members, whether you have an individual plan or are an employee of a small business. If you check the directory and are still not sure, you can always call our member services department at 877.514.2442.

Do CGHC plans include prescription drug coverage? How can I find out if my medication is covered?
Yes – all CGHC plans for both individuals and small businesses include prescription drug coverage. Some plans are copay plans where you pay a set amount for various drug “tiers,” while others require you to satisfy your deductible before we begin to cover some or all of the cost. Please check our online formulary to determine if your prescription medication is on our list of generic and preferred drugs. Keep in mind that the formulary describes different “tiers” of drugs, with generic and preventive prescriptions generally costing you the least out of pocket.
Does CGHC offer plans that are compatible with a health savings account (HSA)?

Yes, we offer HSA-eligible plan options on each metal level (for individual/family and small employer plans). You would contact your own financial institution to administer the HSA. For more information, call our Sales department at 855.494.2667 or view our plans online.

What is an HSA plan?

Health Savings Account (HSA) eligible health plans are health insurance plans with a deductible that is high enough to qualify you for tax-advantaged savings on health expenses. To qualify as an HSA-eligible plan, the health plan can only pay for preventative care services and nothing else before the deductible is met.


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.

How can I find out what’s covered?

Our benefits are described in our Certificates of Coverage. Services requiring prior authorization are described in the certificate, as are exclusions and limitations. If you have any questions about our Certificates of Coverage, please call member services at 877.514.2442.

What is medical necessity and what services require Prior Authorization?

Medical necessity describes care that is reasonable, necessary and/or appropriate, based on evidence-based clinical standards of care. CGHC covers only services deemed medically necessary, and therefore, your claims may occasionally be subject to review for medical necessity.


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 877-825-9293 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 1-877-825-9293. This call starts the utilization review process.

Click here to learn more about prior authorization.

What’s not covered?
What if my service or authorization is denied for payment?

If an authorization has been denied, you have the right to appeal that decision. Our cooperative fully supports this process and may change its decision if there is a good reason for doing so based on additional information that you provide. CGHC must complete the appeals process within 30 days. If you aren’t happy with the outcome of an appeal, you can also ask for an external independent review to be conducted. You can find an appeals form at the bottom of this webpage or call Member Services at 877.514.2442 for more information.

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.

Enrollment Questions

How do I enroll in a CGHC plan? What is a Special Enrollment Period?

Small employers can enroll in our employer health insurance plans at any time and may contact our Sales department at 855.494.2667 for assistance. Most individuals and families can only enroll during open enrollment. The open enrollment period runs from November 1 through December 15 every year. During open enrollment you will be able to purchase CGHC coverage directly through our website, by calling our Sales team at 855.494.2667, through your own insurance agent, or by going online to


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.

How do I know if I qualify for a tax credit? is the federal government-run marketplace for health insurance. You can find out if you qualify for tax credits online by visiting their website at, by calling 800.318.2596, by calling our Sales team at 855.494.2667, or by talking to your health insurance broker. The only way to receive a tax credit is for you to buy insurance through, although our company or an insurance broker can help you with that at no cost to you.
Why should I consider working with a broker to help me choose health insurance?

A broker is independent of a health insurance company. Brokers are licensed with the state to sell health insurance, so they know all of the plans the different health carriers offer. A broker can meet with you in person and spend the time needed to explain the coverage that would best meet your needs. There should be no cost to you when you choose to work with a broker.


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.

When will my health coverage begin?

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.

How do I renew my plan?
Common Ground Healthcare Cooperative automatically renews individuals and small employer members into their existing plans unless we receive a termination notice in writing. However, we strongly encourage our members to actively renew with us. You can do this with our help, your broker’s help or through This is the safest way to avoid any miscommunication we might receive from the federal Marketplace (, especially during the busy open enrollment period.
I have not yet received my member packet or ID card since enrolling. When can I expect to get them?

Once you enroll in a health insurance plan and pay your first month’s premium, it will generally take about two weeks for us to generate your membership materials and send them to you. You can view materials and print a temporary ID card by going to our Pay My Premium portal.


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.

Why does the cost of health insurance keep going up?

CGHC’s mission is to make coverage for our members as affordable as possible while maintaining sufficient funds to pay all claims and administrative expenses. New medications, procedures and technologies improve health and save lives, but they can be costly. Pharmaceutical companies and health providers have to be paid from member premiums.


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.

Looking for your 1095 TAX FORM?

Your 1095 tax form comes from different entities depending on the type of health plan you purchased.

1095-A: Health Insurance Marketplace Statement

Most* CGHC plans offered through the Federal Marketplace receive form 1095-A


If you enrolled in a CGHC health plan that is offered on the federal Marketplace (Exchange), you will receive form 1095-A from the government. The 1095-A form provides details about your advance premium tax credit (APTC). It will show the total APTC that you received in previous year. You must file a federal income tax return if you or another member of your household wants to claim the tax credit.


The 1095-A form will be mailed by the government on or before January 31st. If you have any questions about your 1095-A, please contact the Federal Marketplace.


If you need your 1095-A form before it arrives via US mail, you may download it from your account. How to Find Your 1095A Form on


*Catastrophic plans are the exception. Members with a Catastrophic plan that is offered through the Federal Marketplace will receive form 1095-B.


1095-B Health Coverage Form

CGHC plans offered outside of the Federal Marketplace and Catastrophic plans receive form 1095-B. You do not need to file form 1095-B with your taxes.


If you enrolled in a CGHC health plan that is not offered through the Federal Marketplace (Exchange) or a Catastrophic plan, CGHC will send you form 1095-B. We will mail the form on or before March 3, 2023.


Form 1095-B serves as “proof” that you had health insurance coverage with CGHC for the time period described on the form. We recommend checking that the information on the form is correct. We also suggest you keep a copy for your records.


If you have questions about the 1095-B form you receive from CGHC, please contact Member Services at 1.877.514.2442.


EPO Questions

What is an EPO plan?

EPO stands for Exclusive Provider Organization.  This means that members with individual and family plans will only have coverage for care received from in-network providers.  If you see an out-of-network provider, the services will not be covered, except for emergency care, urgent care outside of our service area, or when there are not any in-network providers that are qualified to treat your condition.*


*If you are unable to find an in-network provider to treat your condition, your current in-network provider can request out-of-network services by filling out our EPO Referral Form and submitting it for review.  If services are approved, a written network approval letter will be issued to the referring provider, member, and referred to out-of-network provider.  Prior Authorization may apply after network approval.  If out-of-network services are denied, an in-network provider will be recommended.

Am I covered or urgent and emergency care out-of-network?

Urgent care is when you need non-emergency medical attention and cannot wait to schedule a doctor’s visit. Only if the urgent care service is provided outside of our service area will you have coverage at out-of-network facilities. In that case, the urgent care visit will apply to your in-network benefits including deductibles, coinsurance and copayments. Please be aware that 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” (the appropriate payment amount) based on what other payers pay for the service. If you are inside of our service area, you will need to visit an in-network urgent care facility for the service to apply to your benefits.


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.

If I see an out-of-network provider, what will I owe?

CGHC will only cover out-of-network services in case of an emergency, urgent care outside of the service area, or if there is not an in-network provider who is able to provide the service (which requires approval).  If your out-of-network is not listed here or approved through an EPO referral, you will owe the entire bill to the provider.  There are limited circumstances where non-emergency out-of-network services will be covered within the service area: 1) an in-network provider is not able to provide the service, AND 2) an in-network provider submits an EPO referral for you to see an out-of-network provider, AND 3) CGHC approves the EPO referral BEFORE you receiving the service AND 4) the service is medically necessary and meets our coverage requirements outlined in the Certificate of Coverage available at


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.

You mention the term referral, what does that mean?

CGHC does not require you to obtain a referral to see an in-network specialist.


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

In an EPO, do I need to select a primary care physician and get a referral to see a specialist?

You do not have to select a primary care physician. You also do not need a referral to see in-network specialists.


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.

If I have a dependent child on my plan living outside of CGHC’s service area, are they covered?
Qualified dependents who are currently living away from home are covered for urgent or emergency care that need immediate attention. Follow-up care and any covered elective procedure must be obtained from in-network providers. Costs related to medically necessary urgent and emergency care will apply to your in-network benefits and will be paid by CGHC at our maximum allowable fee (or appropriate payment amount).
What about coverage for full-time student member dependents?
Dependent full-time student members that attend an Institute of Higher Learning within the state of Wisconsin, but outside of the CGHC 25-county service area, have coverage for one clinical assessment by an out-of-network provider and a total of five counseling visits for outpatient behavioral health, substance abuse treatment or any combination of the two. These students will also have the same access to emergency and urgent care as described above. Please refer to the Certificate of Coverage online for further details at

Claims Questions

What am I responsible for paying for when using out-of-network care? Will I get billed by the doctor?

Because CGHC now offers Exclusive Provider Organization (EPO) plan designs for individuals and families, our members do not have out of network benefits except in case of emergencies, urgent care services outside of our service area among others. For more details please review the 2018 Certificate of Coverage. For limited circumstances, we will consider approving out of network care if an in-network provider is not qualified to provide the medically necessary covered service. An in-network provider must submit a referral form for us to review before out of network services can be received.


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.

How do I submit my health care claims?

Typically, healthcare providers, including pharmacies, will submit claims to Common Ground Healthcare Cooperative on your behalf. If a claim is not submitted by your provider, we have no way of knowing that you received services.


If 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 received 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 or if you received medical care when traveling outside of the United States (foreign claim), and you are an individual or small group member and enrolled in one of our Envision plans, please complete this form. Mail the completed form with receipts, proof of payment, and an English translation for any notes or documentation to:

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

How do I appeal a denial or get an exception to obtain a mediciation not on the formulary?

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.


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 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 You may file a civil action under section 502(2) of the Employee Retirement Income Security Act (ERISA) once you exhaust the grievance procedure.

How does coordination of benefits work if I have other coverage?

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.

Do you ever deny claims retroactively?

It is generally not Common Ground Healthcare Cooperative’s practice to deny claims retroactively. There are only a few circumstances in which this could happen:

  • 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
How can I share my healthcare information and data?

Common Ground Healthcare Cooperative (CGHC) is happy to provide members with easy access to their healthcare data via either a web portal or a mobile app of the member’s choosing. Before enrolling in this service, CGHC recommends you learn more about Protecting your Data and Selecting an App.


To utilize this feature of your coverage you will need to:

  1. Obtain an invitation code for enrollment purposes by calling our Member Services team at 877-514-2442.
  2. Visit our Connected Health web page and click the “Enroll” button.
  3. Enter the invitation code given to you by our Member Services team and click “Next”.
  4. Enter your Member ID from your insurance card (be sure to include leading-zeroes and any dashes).
  5. Enter your date of birth and your zip code and click “Next”.
  6. Select your mobile phone number and click “Send Code”.
  7. Enter the verification code you receive via the text message and click “Next”.
  8. Select or enter an email address to receive a security code and click “Next”. This will become your username.
  9. Enter the security code you receive in your email to confirm your identity.
  10. After your email is confirmed, you will be asked to create a password.
  11. Your account setup is now complete. Click on the Sign in link to sign into your account.


If you have any questions or need additional assistance, please contact us!