Common Ground Healthcare Cooperative (CGHC) maintains an internal process for investigating and resolving complaints, grievances, and appeals. Members may file a complaint, grievance, or appeal about any aspect of care or service provided to them by CGHC and/or our contracted providers. Our internal process ensures we carefully consider each complaint, grievance, or appeal that we receive. We strive to complete each investigation as quickly as possible.
WHAT IS A COMPLAINT?
Anytime you, or your authorized representative, verbally express dissatisfaction to us, we record it as a complaint. You might be unhappy about CGHC, our contracted providers, or a vendor who provides services on our behalf. Whatever your concern, we take all member complaints seriously. We respond to each in a proper and timely manner.
How to submit a complaint – please contact our Member Services Team at 1-877-514-2442. Some examples of complaints include: wait time in a doctor’s office, ability to schedule appointments, billing, and claims practices.
WHAT IS A GRIEVANCE?
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)
All grievances follow the same process. However, the time limit differs based on medical need.
How to submit a grievance – You, or your authorized representative, can file a grievance request by using the form. You can get the form from our website at: https://commongroundhealthcare.org/faq/.
When completing the form, please include all details of your case (name, address, phone number, claim number, what you are asking CGHC to do, such as review a claim denial, along with the reason).
Once you complete and sign the form, you may fax, mail, or email it to CGHC.
- Fax: 262-754-9690 Attention Appeal & Grievance
- Mail: Attention CGHC Appeal & Grievance , 120 Bishop’s Way, Suite 150, Brookfield, WI 53005
- Email: Grievance@CommonGroundHealthcare.org
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 grievances are carefully researched. We will resolve the request within thirty (30) days unless an extension is needed. If an extension is needed, we will send you a letter. The letter will explain why we need more time (such as when we are waiting for information from a provider). The letter will also include the date we anticipate being done. After the meeting, you will receive an outcome letter that explains the decision of the committee.
Next step after the CGHC Grievance process – Contact the Office of the Commissioner of Insurance (OCI)
If a grievance is not resolved in your favor, you may file a complaint with the Office of the Commissioner of Insurance (OCI). This is the state agency that enforces Wisconsin’s insurance laws. Complaints can be filed online or by mail.
- Website: WI.gov/Pages/Consumers/Filing-a-Complaint.aspx
- Mailing address: Office of the Commissioner of Insurance, O. Box 7873, Madison, WI 53707-7873
To request a complaint form, call 1-800-236-8517 (tollfree within Wisconsin) or 1-608-266-0103.
WHAT IS AN APPEAL?
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) All appeals follow the same process. However, the time limit differs based on medical need.
How to submit a standard appeal – You, or your authorized representative, can file an appeal request by using the form. You can get the form from our website: https://CommonGroundHealthcare.org/FAQ.
When completing the form, please include all details of your case (name, address, phone number, prior authorization number, service or medication being requested). Be sure to provide evidence of why the service or medication is needed. For example, provide medical records, physician notes, journal articles, clinical trial information, which apply.
Once you complete and sign the form, email, fax or mail it to CGHC.
- Fax: 262-754-9690 Attention Appeal & Grievance
- Mail: Attention Appeal & Grievance , 120 Bishop’s Way, Suite 150, Brookfield, WI 53005
- Email: Grievance@CommonGroundHealthcare.org
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 are carefully researched. We will resolve the appeal within thirty (30) days 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 to request an EXPEDITED appeal or grievance (24 or 72-hour time limit)
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
Next step after CGHC Appeal – MAXIMUS Federal Appeal
If a CGHC appeal decision is not in your favor, you may request an external review of that decision. MAXIMUS Federal Services is the certified independent organization that reviews denied CGHC appeals. A written request must be submitted to MAXIMUS Federal Services within four (4) months of the date on the CGHC letter containing the appeal denial decision.
Complete and submit the request form online or print and fax or mail the completed form to MAXIMUS Federal Services.
- Online submission: https://externalappeal.cms.gov
- Mail: MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534
- Fax: 1-888-866-6190
To request an expedited review by MAXIMUS Federal Appeal, please check the box on the submission form. Be sure to explain why expedited review is needed.
Need more details? Please See your Certificate of Coverage, which you can find on our website: