a procedure or service for your patients to avoid claim denials.
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.
For resources to help you navigate prior authorizations for CGHC members, use these materials:
Electronic Prior Authorization (ePA) and Formulary Exception Requests – Optum’s preferred method
Please submit ePA requests or formulary exception requests to OptumRx using the online portals.
For Urgent PA or Exception Requests, Call OptumRx at 1-800-711-4555 (Monday through Friday: 5am PST to 10pm PST). Telephone requests can also be made if you cannot submit requests through ePA.
IMPORTANT: When submitting an authorization request on the OptumRx website, be sure to include all relevant information including medical records to support your request. Missing information could cause in a delay or denial of the prior authorization or exception request.
If you do not agree with a prior authorization decision, you can speak with a physician or healthcare professional reviewer by calling OptumRx Prior Authorization department at 1-855-577-6545 and ask to initiate a “Peer to Peer Review.”
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:
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.
Please note, referrals are only considered in rare circumstances and are generally NOT necessary for the following services:
* Please note follow-up care is not covered at out-of-network facilities.
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.
Pursuant to 45 CFR § 149.140(d)(1), the following disclosure addresses payments under 45 CFR §§ 149.110, 149.120, or 149.130:
If you have questions about this information, visit cms.gov/nosurprises or contact CGHC at 877-514-2442.
Download guideline PDFs here:
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
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:
*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.