Coverage Details

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.

The CareSource Medical Management team oversees the PA process with our partners listed below. The PA decision letter that you receive may include this company’s name and logo:

• • Imaging and Related Services – Evolent
  • Cardiac and Orthopedic/Musculoskeletal Surgeries/Procedures – TurningPoint
  • Medications and Other Pharmacy Services – CareSource RxInnovations

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.

• For medications, the PA process can take up to 72 hours.
  • If your situation is medically urgent, your provider can request an expedited PA process.
  • To verify the status of a drug PA request, call Member Services at 1-877-514-2442.
• 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, login to your account on MyHealth Portal or call Member Services.
• For an urgent or emergency hospital admission, your provider needs to submit the authorization request within 48 hours of admission. We will provide a decision within 24 hours of receiving the needed information.

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 (PA) Tips

• During your provider visit, review the:
  • Formulary when your provider writes a prescription to see if the drug needs prior authorization.
  • Prior Authorization Frequently Requested Services whenever your provider suggests a medical service, test, or procedure. Your provider should also search the Prior Authorization List on the CareSource and CGHC Provider page.  The list includes codes for medical benefits that require PA. If the planned service is not on the list, your provider can call Member Services at 1-877-514-2442 to verify whether PA is needed.
• Contact your provider to verify that the PA request has been submitted.
  • Your provider can find instructions and links for submitting prior authorization requests on the CareSource and CGHC Provider page.
• After your provider submits the PA request, you can check status:
  • Medical or behavioral health services – login to your account on My Health Portal or call Member Services at 1-877-514-2442.
  • Medications and other pharmacy services – call Member Services at 1-877-514-2442.
• Wait for a written PA decision (approval or denial).
  • You need to receive written PA approval BEFORE you receive a service or medication that requires prior authorization. You and your provider will receive a letter that will tell you whether the PA is approved or denied.
• Read the PA approval letter carefully. You need to understand:
  • Which service(s), drug(s) or equipment have been authorized.
  • Who (provider and location) is authorized to deliver the service(s).
  • The time period you are authorized to receive the service(s).
• If the PA request was denied, your provider has the option to ask for:
  • A reconsideration if information was missing from the original request.
  • A peer-to-peer consultation
  • An appeal of the decision on your behalf
• 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, which must include documentation to explain why more care is needed.
• If you have other insurance, written PA approval is needed from CGHC.
  • Whether CGHC is your primary or secondary insurer, our PA approval is needed for certain services or drugs to be covered under our plan.
• You are responsible for any cost share (copay, deductible and/or coinsurance) that applies.
  • Log in to your Pay My Premium Portal account and view your plan’s Schedule of Benefits to see any cost share that may apply.
• The provider must submit the claim timely, with correct codes.
  • If the claim we receive does not match the PA approval letter, the service may not be covered.

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.
• To receive a printed copy of the COC, please contact Member Services at 1.877.514.2442.