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Provider Resources and Training

Prescription Drug Information

2024 Prescription Drug List (Formulary)

2024 Pharmacy Network

2024 Preventive Drug List

 

Prior Authorization Search

For dates of service starting 12/01/2024 and forward access our searchable prior authorization list or use the CareSource Procedure Lookup Tool.

 

 

Log into the CareSource portal to request any prior authorizations.

 

Prior Authorization Information

For Prior Authorization (PA) questions or to check status call  877-514-2442.

 

 

Please submit PA requests as follows:

 

 

 

 

 

 

 

CGHC follows NCQA guidelines in reviewing prior authorization requests and making determinations, but it is important that providers submit Prior Authorizations timely to ensure enough lead time for a member’s services.

 

Please note that for urgent or emergency admissions, Prior Authorization must be obtained within 48 hours of the admission or the next business day. Approval of an elective inpatient admission to a facility is required prior to the elective services being received. We will notify the member in writing of the decision regarding a determination for elective outpatient services.

 

If the provider determines that additional care beyond the services specified or the length of time originally authorized is medically indicated, we must be contacted to request an extension of the original authorization. The member and the provider will be notified whether the request for an extension is approved or denied.

 

Prior Authorization must be obtained regardless of whether Common Ground Healthcare Cooperative is the patient’s primary or secondary health insurance carrier. Prior Authorization does not guarantee coverage and/or payment if a benefit maximum has been reached or coverage has been terminated.

Prescriptions requiring Prior Authorization

Please submit completed prescription authorization requests via phone by calling 1.800.711.4555 or electronically through go.covermymeds.com/OptumRx.

 

Click here to access Optum Rx’s specific drug forms.

 

If you cannot find the prior authorization form you are looking for by visiting OptumRx’s website, please complete the general prescriptions form here.

 

NOTE: When submitting an authorization request, it is important to use Drug Specific forms when applicable. Please use the most up-to-date forms on OptumRx’s website and be sure to include all of the relevant information. If a submitted request is missing information the request(s) can be delayed or denied due to lack of information.  Please check for the drug specific form because the use of out dated  or general forms may not contain all required elements and could result in a delay or denial of the authorization request.

Common Ground Healthcare Cooperative works collaboratively with providers to ensure that our members receive the highest quality, most cost-effective care possible. Our network highlights integrated care systems that focus on improving the health of the community by providing the right care in the right setting at the right time. If you are currently a provider working with us, you a part of our Envision network, which is offered for both individual and small group coverage. If you have any questions, please contact us at 877.514.2442. Use the following resources for reference:

Claims Submission

For dates of service 01/01/2025 and after, Providers can submit claims through the secure online provider portal.

 

To submit claims electronically:

 

  • Providers must work with an electronic clearinghouse. CGCH will accept electronic claims through Availity.
  • Electronic funds transfer (EFT) is offered as a payment option through ECHO.

 

Additional information regarding these options and claims submission as of 01/01/2025 can be found in our updated provider manual or by visiting the following site:  https://www.caresource.com/wisconsin

For dates of service through 12/31/2024:

The instructions are as follows:

 

CGHC contracts with Smart Data Solutions (SDS) for facilitation of EDI claim submission and real time benefits/coverage and claim status inquiries.

  • Providers interested in using the Common Ground Healthcare Provider Portal for Online Claim Submission and Eligibility Verification can register with SmartData Solutions by clicking here. Should you need assistance with your claims submission or have portal questions, please contact SmartData Solutions Provider Support at 855.297.4436.
  • For EFT payment(s) please register with InstaMed by clicking here. InstaMed offers support to users Monday through Friday 6:00 am to 8:00 pm Central Time. Please call 215.789.3680 with your questions.

Referrals

Click here for more details regarding our referral process for out-of-network care.

Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:

    • Emergency Care
    • Urgent Care
    • Maternity care for new members in 3rd trimester of pregnancy (prior authorization is required)
    • Full-time students enrolled in Institutes of Higher Learning seeking behavioral health or substance abuse disorder treatment outside of CGHC’s services area but within the state of Wisconsin.

* Please note follow-up care is not covered at out-of-network facilities.

Provider referral form

QPA Disclosure Statement

QPA Disclosure Statement

Common Ground Healthcare Cooperative (CGHC) uses the Qualifying Payment Amount (QPA) as the recognized payment amount for all items and services protected from balance billing under the No Surprises Act. The Payment Amount on the Explanation of Payment represents the QPA calculated by CGHC.

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Pursuant to 45 CFR § 149.140(d)(1), the following disclosure addresses payments under 45 CFR §§ 149.110, 149.120, or 149.130:
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    1. Certification: CGHC certifies that, based on our determination—
      • The qualifying payment amount (QPA) applies for purposes of the recognized amount (or, in the case of air ambulance services, for calculating the CGHC member’s cost sharing); and,
      • Each QPA shared with the provider or facility was determined in compliance with 45 CFR § 149.140, Methodology for calculating qualifying payment amount.
        .
    2. Open Negotiation: If the provider or facility wishes to initiate a 30-business-day Open Negotiation Period for purposes of determining the amount of total payment, send a completed Open Negotiation Notice Instructions and Form to NSAClaims@commongroundhealthcare.org or by fax to 262-754-9690. The notice must be sent to CGHC within 30 business days after the initial payment or denial of payment to the provider or facility.
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    3. Independent Dispute Resolution: If the 30-business-day Open Negotiation Period does not result in an agreement on final payment, the provider or facility may initiate the federal Independent Dispute Resolution (IDR) process within 4 business days after the end of the Open Negotiation Period.

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If you have questions about this information, visit cms.gov/nosurprises or contact CGHC at 877-514-2442.

Clinical Practice Guidelines

For dates of service 12/01/2024 and after, please view our policies at the following site:  https://www.caresource.com/wisconsin

 

For dates of service through 11/30/2024: The instructions are as follows: 

CGHC’s Clinical Practice Guidelines and clinical policies

 

Download guideline PDFs here:

Health Equity Education

CGHC believes that everyone deserves the best treatment regardless of their race, gender, sexual orientation, socioeconomic or cultural characteristics. We are committed to providing high-level care to all members and removing obstacles and disparities that exist in the health care system.

 

Click on the following link to access free continuing education e-learning (Culturally and Linguistically Appropriate Services in Maternal Health Care, Behavioral Health, Oral Health) offered by the U.S. Department of Health and Human Services, Office of Minority Health: https://thinkculturalhealth.hhs.gov/education

Step Therapy

OptumRx PA guidelines* are listed by drug and include the drug indications, guideline type (step therapy, PA, initial or reauthorization), approval criteria and duration, effective and change dates, and more. They are based on written, pharmaceutical UM decision-making criteria** that are objective and developed from clinical evidence from the following sources:

 

  • Food and Drug Administration (FDA) information
  • Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-analyses, review articles, comparative effectiveness research, evidence-based medicine reviews, healthcare technology assessments, and pharmacoeconomic and outcomes research
  • Treatment guidelines, practice parameters, policy statements, consensus statements created/endorsed by reputable governmental, medical, and/or pharmacy organizations
  • Pharmaceutical, device, and/or biotech company information
  • Medical and pharmacy tertiary resources, including those recognized by CMS
  • Relevant and reputable medical and pharmacy textbooks and or websites

 

*These are specific to health plans and insurers utilizing our Select and Premium drug lists only. Your patient’s prescription drug benefits may be covered under his/her plan-specific formulary for which these guidelines may not apply. We recommend you speak with your patient regarding  Prescription drug benefit coverage under his/her health insurance plan.
**OptumRx’s Senior Medical Director provides ongoing evaluation and quality assessment of the OptumRx UM Program.

 

OptumRx Prior Authorization and Exception Request Procedures
Submitting an electronic prior authorization (ePA) request to OptumRx ePA is a secure and easy method for submitting, managing, tracking PAs, step therapy and non-formulary exception requests. It enables a faster turnaround time of
coverage determinations for most PA types and reasons.

Login to your preferred web-based portal account and select “New Request” within your Dashboard to submit your PA request.

Provider Newsletters

Twice per year, we send out a provider e-newsletter which gives important updates, changes, and information to our provider partners. Read them here:

Other Provider Resources

There are other helpful resources that we are providing to you to enhance healthcare quality as per NCQA standards.

*Machine Readable Files (MRF) require the use of specialized software to be opened and viewed. Common Ground Healthcare Cooperative does not provide or support any software needed to view these files.