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. If you check the directory and are still not sure, you can always call our member services department at 877.514.2442.

Yes, we offer HSA-eligible plan options on each metal level. 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.

Health Savings Account (HSA) compatible 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 preventive care services and nothing else before the deductible is met.

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Purchasing an HSA compatible 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.

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.

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.

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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.

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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.

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Click here to learn more about prior authorization.

Most individuals and families can only enroll during open enrollment. The open enrollment period runs from November 1 through January 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 www.Healthcare.gov.

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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.

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.

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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.

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.

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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.

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.

• Online, go to HealthCare.gov/taxes
• Or call: 1.800.318.2596

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

*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 to you by March 31st.

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.

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Premium is due on the 25th day of the month prior to the month of coverage. For example, for July coverage your premium is due on June 25. Paying your premium by the due date ensures you avoid an interruption in your coverage.

• Pay Online

Pay My Premium Portal is the easy way to make premium payments online. You may use your credit card, bank card, or checking account to make an initial one-time payment. Please note – you will need to supply your date of birth and last four digits of your social security number to complete the registration process and make payments online. You can watch a video about making a one-time payment online.

• Pay by Phone

Pay your premium by phone using our interactive voice response (IVR) system – available 24/7/365. You may pay using your credit card, bank card, or checking account. Paying by phone is a single occurrence method. Recurring payments cannot be set up when paying by phone. Call 1-877-514-2442 and follow the voice prompts.

• Pay by Check

Mail a personal or cashier’s check or money order with the remittance stub from the bottom of your invoice to our lockbox. See the Contact page of our website for mailing address details.

If you are missing your payment stub, please be sure to note your member ID number on your check or money order. This will ensure your payment is credited accurately and efficiently.

• Pay on the Health Insurance Marketplace® (Exchange) / Healthcare.gov

If you purchased your plan on the Health Insurance Marketplace (Healthcare.gov), you have the option to make your initial payment via the Exchange. Simply click the payment button on your application.

• Pay Online

Pay My Premium Portal is the easy way to make premium payments online. Register to pay using your credit card, bank card, or checking account. Make a one-time payment (watch a video about making a one-time payment online) or set up recurring payments to ensure your premium is received on the 25th of each month. Please note – you will need to supply your date of birth and last four digits of your social security number to complete the registration process and make payments online.

• Pay by Phone

Pay your premium by phone using our interactive voice response (IVR) system – available 24/7/365. You may pay using your credit card, bank card, or checking account. Paying by phone is a single occurrence method. Recurring payments cannot be set up. Call 1-877-514-2442 and follow the voice prompts.

• Pay by Check

Mail a personal or cashier’s check or money order with the remittance stub from the bottom of your invoice to our lockbox. See the Contact page of our website for mailing address details.

If you are missing your payment stub, please be sure to note your member ID number on your check or money order. This will ensure your payment is credited accurately and efficiently.

After your initial payment has processed (typically less than 24 hours), you will be able to set up recurring payments.

Login to the Pay My Premium Portal and click Payment Options. Follow the prompts to complete your set up.

If you have an agent or broker, they can help you set up recurring payments.

When a payment is declined, all future recurring payments are cancelled. This could occur for many reasons such as an expired credit or debit card, wrong account number, NSF (insufficient funds), etc.

When this happens, you will be notified via email.

To correct this, you will need to login to the Pay My Premium Portal, update the payment method and reactivate the recurring payment.

Login to the Pay My Premium Portal. Then click Transaction History to see all payments credited to your account. You will be able to see any payment that was applied to your account (i.e., made by check, online, or by phone).

If you’re late paying your premium (bill), you will enter into a grace period, which is a short period of time during which you can “catch up” on your payments and avoid losing your health coverage.

The grace period is a short period of time during which you can “catch up” on your payments and avoid losing your health coverage. How the grace period works will differ based on whether or not you have an advance premium tax credit (APTC).

If you have an advance premium tax credit (APTC), you will have three (3) months to pay your account in full. Keep in mind that during the 3-month period, your balance due will continue to increase as the premium for each month of coverage is added.

• We contact your doctor and pharmacy to let them know you are in a grace period.
• Your benefits will be suspended until you get caught up. This may prevent you from getting your prescriptions and seeing your doctor.
• The grace period will remain in effect until you pay the total balance due, or the grace period expires.
• Payments made during the grace period will apply to the oldest unpaid month of coverage.
• If you fail to pay the full amount before the grace period ends, your coverage will be terminated retroactively.
• If your coverage is terminated for non-payment, you will be responsible for 100% of the cost of services and prescriptions incurred during your grace period, as defined by the Centers for Medicare and Medicaid Services (CMS) guidelines. To learn more about grace periods, visit Healthcare.gov.
• If coverage is terminated, you may not be able to reapply for coverage until the next open enrollment period, unless you have a qualifying life event. To learn more about grace periods, visit the Healthcare.gov

If you don’t have a premium tax credit, you get one month to pay your account in full. Keep in mind that during the 1-month period, your balance will continue to increase as premium for the next month of coverage is added.

• Your benefits will be suspended until you get caught up. This may prevent you from getting your prescriptions and seeing your doctor.
• The grace period will remain in effect until you pay the total balance due, or the grace period expires.
• If you fail to pay the full amount before the grace period ends, your coverage will be terminated retroactively.
• If your coverage is terminated for non-payment, you will be responsible for 100% of the cost of services and prescriptions incurred during your grace period.
• If coverage is terminated, you may not be able to reapply for coverage until the next open enrollment period, unless you have a qualifying life event.

A late fee will not be applied to your balance. If you miss a payment, your policy will move to a grace period status. During the grace period, your access to doctor visits and prescriptions are limited until your account is paid in full.

Making a partial payment will not end the grace period. A partial payment will also not change the end date for the grace period.

Once a policy enters into a grace period, the account must be paid in full for the policy to be in good standing.

If the balance is not paid in full by the end of the grace period, coverage will be terminated retroactively.

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.

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.*

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*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.

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.

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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.

CGHC will only cover out-of-network services in the case of 1) an EMERGENCY, 2) URGETN CARE OUTSIDE OF THE SERVICE AREA, or 3) IF THERE IS NO IN-NETWORK PROVIDER WHO IS ABLE TO PRIVIDE THE NON-EMERGENCY SERVICE. The latter requires a CGHC-approved authorization request to see  the out-of-network provider.

There are limited circumstances where NON-EMERGENCY out-of-network services will be covered within the service area: 1) no in-network provider is able to provide the service; AND 2) the request to seek out-of-network services is submitted by an in-network provider; AND 3) out-of-network authorization is approved by CGHC before you receive the service; AND 4) the out-of-network provider has received prior authorization (PA) for the service. PA verifies that the service is medically necessary and meets the requirements outlined in the Certificate of Coverage.

Cost-sharing amounts (copayments, deductible and/or coinsurance) will apply to covered out-of-network services, the same as if the provider were in network.

Balance Billing could apply to any out-of-network service that is not covered under the No Surprises Act. Balance billing occurs when the provider sends you an invoice for  the difference between the amount they charged and the maximum allowed amount that CGHC paid towards the service.

YOU DO NOT NEED TO OBTAIN A REFERRAL TO SEE A CGHC IN-NETWORK SPECIALIST. However, because all CGHC health plans are Exclusive Provider Organization plans, you do need CGHC-approved authorization to see an out-of-network provider for any non-emergency service. This is separate from the prior authorization process, which is also required.

There are limited circumstances where non-emergency out-of-network services will be covered within the service area: 1) no in-network provider is able to provide the service; AND 2) the request to seek out-of-network services is submitted by an in-network provider; AND 3) out-of-network authorization is approved by CGHC before you receive the service; AND 4) the out-of-network provider has received prior authorization (PA) for the service. PA verifies that the service is medically necessary and meets the requirements outlined in the Certificate of Coverage.

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

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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.

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 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.

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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.

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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.

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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.

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

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.

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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.

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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.

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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 ocicomplaints@wisconsin.gov. 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.

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If your plan is employer-sponsored and governed by ERISA, you may contact the Employee Benefits Security Administration at 866.444.3272 or askebsa.dol.gov. You may file a civil action under section 502(2) of the Employee Retirement Income Security Act (ERISA) once you exhaust the grievance procedure.

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.

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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

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.

CGHC is a not for profit health insurance company. We offer health plans that are available on the Health Insurance Marketplace® (On-Exchange) at the government website HealthCare.gov. We also offer health plans outside of HealthCare.gov (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 HealthCare.gov. 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 HealthCare.gov. 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 HealthCare.gov/glossary 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 HealthCare.gov website – even if you started on the CGHC website. CMS, via HealthCare.gov, 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 HealthCare.gov 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)

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 HealthCare.gov website.

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 Pay My Premium Portal. You can view the full plan name on the Schedule of Benefits (SOB) or Summary of Benefits and Coverage (SBC).

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 HealthCare.gov website also offers a glossary, which is another great place to find answers.

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

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

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 based on the best information available to us at the time of our rate filing.

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.

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: www.hhs.gov/hipaa/for-individuals/

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.

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.

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)

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.

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

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 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.

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.