Transition Your Care
We want to ensure our members have a smooth transition to GHC-SCW. Our Care Management Team is available to help. The Care Management Team encourages members to review the
Transition of Care document to anticipate any concerns.
In the event you need specialty care, your Primary Care Provider (PCP) will help you initiate the referral/prior authorization process. As a member, you have access to a wide variety of outstanding specialty care providers. See your Benefits Summary and Member Certificate for full details on services requiring prior authorization, and talk with your PCP before accessing most specialty care services.
Planned specialty visits outside of the GHC–SCW primary care networks require coordination by your PCP. Members must receive an approval letter from the GHC–SCW Care Management Department before receiving these services. If you make an appointment with a specialist without first obtaining an approval letter from GHC–SCW Care Management, you may be responsible for full payment of the services provided.
Contact Care Management at
(608) 257-5294 or
(800) 605-4327 Ext. 4514 and a member of the Care Management Team will assist you with continuity of care or transitioning to a GHC-SCW specialist.
The referral request begins when you visit your PCP and a decision is made to refer you to a specialist. An order is placed in your Electronic Medical Record (EMR), which sends a message to the Care Management Department. The Care Management Team will evaluate the order to determine if it is a covered benefit and review it against national care guidelines to determine if care is medically necessary.
Most referral decisions will be made within four or five business days. Up to 15 days are allowed for review if additional information is needed by the Care Management Team and/or the Medical Director or Physician Reviewer.
An approval letter will be mailed to you and the specialist when the Care Management Team approves the referral request. At that point, you may schedule an appointment to see the specialist. Please take your approval letter to your appointment as it is not always seen in the specialty EMR.
GHC–SCW approves services or supplies based on the information that is available at the time of the approval/denial decision. Approval does not guarantee a member's eligibility or benefits under his or her health plan. It is the responsibility of the member to know their deductible, co–pay or co–insurance amounts that apply to specialty 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, the GHC–SCW Care Management Team will notify you of the denial decision.
The GHC-SCW Member Self-Referral program allows members to schedule appointments without prior authorization for the following services:
- Emergency conditions at an In-Plan facility
- Mental health care at an In-Plan facility
- Alcohol and drug addiction services at an In-Plan facility
- OB/GYN at an In-Plan facility
- GHC-SCW eye examinations
- GHC-SCW chiropractic
- GHC-SCW podiatry
- GHC-SCW physical therapy/occupational therapy
Please check your Benefits Summary for full coverage details. The specialty care you receive must be within your network. These exceptions do not apply to PPO Plan members. Contact the GHC-SCW Care Management Department if you have questions regarding the referral/prior authorization process at (608) 257-5294.