Exceptional Specialty Care at GHC-SCW
Specialty care is care from providers with medical training in a specific area. GHC-SCW offers members access to exceptional specialty care providers with services available right in our GHC-SCW clinics. These include:
World-Class Specialty Care Partnerships
Your Primary Care Provider (PCP) might decide that you need to see a specialist for your care outside of a GHC-SCW clinic. For decades, GHC-SCW has partnered with world-class specialists at UW Health, UW Hospital and other leading community hospitals and clinics. This means our members have access to an elite network of hundreds of specialty providers who are the best at what they do.
We’re here to help. Contact GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327, and request Member Services.
Specialty Care Frequently Asked Questions
The easiest way to find out which specialty services are covered under your insurance plan – or if you need Prior Authorization (approval from GHC-SCW) – is to read your Member Certificate and Benefits Summary.
GHC-SCW members can schedule appointments and receive care without prior authorization or referral from your PCP for the following:
- Emergency conditions at an In-Plan facility
- Behavioral health or mental health outpatient therapy at any In-Plan facility
- Psychiatric outpatient care at any In-Plan facility
- Outpatient alcohol and drug addiction services at any In-Plan facility
- OB/GYN at an In-Plan facility
- Eye exams at GHC-SCW
- Chiropractic care at GHC-SCW
- Podiatry at GHC-SCW
- Physical therapy/occupational therapy at GHC-SCW
Some specialty services require a Prior Authorization before receiving them. Here’s how that process works.
- You visit your PCP or behavioral health provider and decide together that you should see a specialist.
- Your PCP or behavioral health provider will put an order in your electronic medical record, which sends a message to the Care Management department.
- Sometimes that referral request is automatically approved while you’re still in the office.
- If the referral request must be reviewed, our experienced Care Management team will evaluate the order. They will determine if the order is a covered benefit, and review it against national care guidelines if it is medically necessary.
- Most decisions happen within 48 hours, but we could take up to 15 days if Care Management or the GHC-SCW Medical Director needs to review the decision.
- You need to wait until you get an approval or denial letter from the GHC-SCW Care Management department to receive your care. If you get the service without first obtaining an approval letter from GHC–SCW Care Management, you may be responsible for the full bill.
- While GHC-SCW is reviewing your care request, check your Benefits Summary for details on your coverage. The specialty care you get has to be within your network and detailed under your health plan.
When your request is approved, you’ll get a letter in the mail. Then you can schedule your appointment to see the specialist. Members must receive an approval letter from the GHC–SCW Care Management Department before getting care.
Approval does not guarantee member’s eligibility or benefits under their health plan. It is the responsibility of the member to know their deductible, co-pay or co-insurance amounts that apply to specialty services. You can find that information in your Benefits Summary or by talking to Member Services.
If your request is denied, you will receive a letter in the mail explaining the reason for the denial and your member appeal rights.
If your appointment has already been scheduled for the same day or next day after the denial decision is made, you will receive a call from the GHC-SCW Care Management department to notify you of the denial decision.
If you make an appointment without approval from GHC-SCW Care Management, you may be responsible for full payment of the services provided.
GHC-SCW approves services or supplies based on the information that is available at the time of the decision.
Contact the GHC-SCW Care Management Department if you have questions about the referral/prior authorization process at (608) 257-5294.