Prior Authorization
Common Ground Healthcare Cooperative (CGHC) evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.
Services That Require Prior Authorization
Effective December 1, 2024, please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CGHC should be authorized before the service is delivered. CGHC will not pay claims for services in which prior authorization is required but not obtained by the participating provider.
Prior Authorization Submission Options
The Provider Portal is the preferred and faster method to request prior authorization for health care services. You can receive immediate approval and also review the status of an authorization.
| Method | Contact Info |
|---|---|
If you need assistance with submitting your prior authorization or have questions regarding submissions via the portal, please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. | |
Phone | |
Common Ground Healthcare Cooperative |
Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.
Non-Participating Providers
Prior authorization must be obtained before sending patients to non-participating providers, with the following exceptions:
Emergency Services
All inpatient services require prior authorization. Please call 1-877-514-2442 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.
Urgent care received by non-participating provider when travelling outside the service area does not require a prior authorization.
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider, unless the observation setting service is greater than 48 hours.
To request prior authorization for observation services as a non-participating provider or to request authorization for an inpatient admission, please call 1-877-514-2442 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Medical Management department.
Please call 1-877-514-2442 for any questions related to post-stabilization services.
Peer-to-Peer Process
Beginning December 1, 2024, CGHC will provide the opportunity for providers to discuss the Utilization Management (UM) medical necessity determination of a denial or decrease in level of care with the Medical Director/Behavioral Health Medical Director or designee within seven business days of the notification of the determination.
The peer-to-peer process is independent of the appeal process and does not impact the timeframe a member and/or provider has to appeal.
Peer-to-peer rights are separate and distinct from your clinical appeal rights. If you received an authorization denial, your peer-to-peer rights were provided in your denial letter. Please refer to your denial letter to exercise your available peer-to-peer rights.
To initiate the peer-to-peer process, please call CGHC’s Utilization Management team at 1-833-230-2168.