Coverage Details
Preventive Care Coverage
Preventive care coverage is coverage for medical services that focus on preventing disease and evaluating a person’s current state of health. Examples include annual well visits, most immunizations, and screening tests such as mammograms.
When it comes to out-of-pocket expenses for certain preventive services, there is a distinction between “no-cost-share preventive care” under the ACA and other services that may be considered preventive by you or your health care provider.
We provide members with a list of no cost-share preventive services. It is important to know the difference between preventive services and diagnostic services. Learn more about preventive vs. diagnostic services.
Understanding Prior Authorization
- Prior authorization (PA) is the practice of getting approval for certain services before receiving treatment or filling a prescription in order for the service or prescription to be covered under your plan.
- To see the list of prescription drugs that require PA approval, please view the formulary.
- For details about medical and behavioral services that require PA approval, please view the Prior Authorization Frequently Requested Services. Your doctor has access to a complete list of services that need PA approval on the provider resources and training page of our website.
Why is prior authorization needed?
We use the PA process to ensure that members receive care and prescription drugs that are medically necessary, reasonable and appropriate. The process is built on evidence-based clinical standards of care. CGHC plan benefits only cover drugs and services that are medically necessary.
Who reviews and decides on the PA request?
The CGHC Medical Management team oversees the PA process with our partners listed below:
- For most medications and other pharmacy services, OptumRX handles the PA process. OptumRX is our pharmacy benefits manager.
- For specialty drugs, Magellan Health handles the PA process.
How do I obtain PA approval for a drug or service?
The first step is to talk with your provider. All providers who participate in the CGHC network should be aware of the PA process. They understand that PA approval must be obtained before they treat you or write prescriptions for certain drugs. Your provider will submit the PA request on your behalf. However, you need to make sure that you receive written PA approval before you receive the service(s) or drug.
Need more details about prescription drug coverage and how to obtain PA approval for drugs? Please review the formulary or call OptumRx 1.855.577.6545.
How long does it take to get prior authorization?
- For medications, the PA process can take 24-72 hours.
- The medical urgency of your situation will affect the time the PA process will take.
- Call OptumRx 1.855.577.6545 for more information or to verify the status of a drug PA request.
- For medical and behavioral health services, the PA process can take up to 15 calendar days.
- Most PA requests are processed within five (5) business days.
- Your doctor should submit the PA request at least 15 calendar days before the planned date of service.
- For an urgent situation, your doctor can request expedited PA review.
- To verify the status of your medical PA request, call Member Services at 1.877.514.2442.
- For an urgent or emergency hospital admission, please call 1.877.825.9293 within 24 hours of being admitted.
- If CGHC is closed, call us on the next business day.
- We will provide a decision within 24 hours of receiving the needed information.
What happens if I don’t get prior authorization?
You (the member) may be responsible for a financial penalty if you fail to get approval before receiving a service or prescription drug that requires prior authorization.
- You could owe 50% per covered service, up to a maximum penalty of $1,500.
- The penalty will apply before deductible, coinsurance, or any other plan payment.
- The penalty will not count towards your out-of-pocket maximum.
Prior authorization tips
- During your provider visit, review the:
- Formulary when they write a drug prescription.
- Prior Authorization Frequently Requested Services whenever they suggest a service, test, or procedure.
- Your provider should also check the Prior Authorization List. They can find it on the provider resources and training page of our website. The list includes codes for services that require PA approval. If the planned service is not on the list, they can call Member Services at 1.877.514.2442.
- Contact your provider to verify that the PA request form has been submitted.
- They can find instructions and forms for submitting prior authorization requests on the provider resources and training page of our website.
- After your provider submits the PA request, you can call to check status:
- For medical or behavioral health services, call Member Services at 1.877.514.2442.
- For drugs and other pharmacy services, call OptumRx 855.577.6545.
- Wait for a written decision (approval or denial) from CGHC.
- You need to receive written approval BEFORE you receive any service or drug that requires prior authorization.
- You and your provider will receive a letter that will tell you whether the PA is approved.
- Read the PA approval letter carefully. You need to understand:
- Which service(s) or drug(s) have been authorized.
- Who (provider and location) is authorized to deliver the services.
- What period of time the authorization is valid.
- Keep your account in good standing.
- PA approval is not a guarantee of payment.
- Your policy must be in effect at the time you receive the authorized services.
- If more care is needed (beyond what was authorized):
- Be sure your provider submits a new PA request.
- The new PA request will ask for an extension of the original authorization.
- It must include documentation to explain why the extension is needed.
- If you have other insurance, written PA approval is needed from CGHC.
- Whether we are your primary or secondary insurer, CGHC PA approval is needed for certain services or drugs to be covered under our plan.
Where can I find more information about prior authorization?
More information about the PA process is in your plan’s Certificate of Coverage (COC).
- The COC is available on the Coverage Details page of our website.
- You can also find the COC in My Health Portal.
- To receive a printed copy of the COC, please contact Member Services. Send an email to info@commongroundhealthcare.org or call 1.877.514.2442.