Utilization Management

    Common Ground Healthcare Cooperative (CGHC) is committed to maintaining the quality and appropriateness of health care services provided to our members. The Utilization Management (UM) department performs all UM activities including prior authorization, concurrent review, discharge planning and other activities. CGHC makes its UM criteria available in writing by mail, fax, or phone and on this webpage.

    Mail: Common Ground Healthcare Cooperative
    P.O. Box 1307
    Dayton, OH 45401-1307

    Fax: 1-844-676-0372

    On an annual basis, CGHC completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

    Prior Authorization

    CGHC understands that you may have questions about prior authorization. Access the Prior Authorization webpage for detailed information.

    Medical Necessity Criteria

    CGHC utilizes nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. CGHC defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. CGHC also has policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to the CGHC Medical Director for further review and determination. Physician reviewers from CGHC are available to discuss individual cases with attending physicians upon request.

    Utilization review determinations are based only on appropriateness of care and service and existence of coverage. CGHC does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

    Our members’ health is always our number one priority. Upon request, CGHC will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CGHC Medical Management Department. If you would like to discuss an adverse decision with physician reviewer, please call the Medical Management department within five business days of the determination.

    Access to Staff

    Providers may call 1-877-514-2442 to get help with any UM questions.

    • Staff members are available from 8 a.m. to 5 p.m. Central Time (CT), Monday through Friday, for inbound calls regarding UM issues.
    • Staff members can receive inbound communication regarding UM issues after normal business hours.
    • Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, 7 days a week.
    • Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line and the Provider Portal.
    • Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
    • Staff members are:
      • Identified by name, title and organization name when initiating or returning calls regarding UM issues.
      • Available to accept collect calls regarding UM issues.
      • Accessible to callers who have questions about the UM process.

    In the best interest of our members and to promote their positive health care outcomes, CGHC supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.

    Member Support Services

    Representatives are available to answer member questions regarding UM.

    • Representatives are available by phone Monday through Friday, except on the following holidays: New Year’s Day, Martin Luther King Jr. Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Day After Thanksgiving, Christmas Eve and Christmas Day.
    • Members may access Member Services by calling our toll-free number, 1-877-514-2442, 8 a.m. to 5 p.m. Central Time (CT).
    • CGHC offers language interpreters for members who need assistance to communicate with CGHC to discuss UM issues. These services are available at no cost to the member. As a provider, you are required to identify the need for interpreter services for your CGHC patients and offer assistance to them appropriately.