Transparency in Coverage
Complete Transparency Information
This page is intended to provide a general, member-friendly overview. The complete document includes additional definitions, responsibilities, regulatory requirements, review processes and timelines.
View the Full Transparency in Coverage Information Page
Your Member Benefit Summary, Member Certificate and other plan documents control when information on this page differs from the terms of your specific benefit plan.
Understanding Your Coverage and Claims
Health insurance rules can sometimes be difficult to navigate. This page provides a general overview of important coverage, claims and payment information for GHC-SCW members.
Your specific benefits depend on your plan. For complete requirements, definitions and regulatory information, review the Additional QHP Transparency in Coverage Information.
Before You Receive Care
Taking a few steps before receiving non-emergency care may help you avoid unexpected costs.
Use In-Network Providers
Whenever possible, receive care from providers and facilities that participate in your plan’s network. You may be responsible for some or all charges when you receive services from an out-of-network provider without prior authorization. Members with POS or PPO coverage may also be responsible for charges above GHC-SCW’s reasonable and customary amount.
Visit our Find a Provider Search Tool to find an in-network Primary Care Provider.
Ask Your Provider About Prior Authorization
Some services, medical equipment, supplies and medications require approval from GHC-SCW before you receive them. Your provider usually submits the prior authorization request. However, you are responsible for confirming that any required authorization has been obtained. An approved prior authorization does not guarantee that GHC-SCW will pay the full cost. Your deductible, copayment, coinsurance and other benefit requirements may still apply.
Learn more about prior authorization.
Pay Premiums on Time
Premium payments must be made by their due dates. Missing a payment may result in claims being delayed or denied and could eventually cause your coverage to end. Grace-period rules depend on the type of plan you have and whether you receive an advance premium tax credit through the Health Insurance Marketplace.
Contact Premium Billing at (608) 251-4156 extension 4587 when you have questions about a payment or account balance.
Understanding Your Coverage and Claims
Balance billing occurs when an out-of-network provider charges you for an amount that your health plan does not cover, beyond your normal deductible, copayment or coinsurance.
Emergency and urgent care may be treated differently. Contact Member Services at (608) 828-4853 or (800) 605-4327 when you receive an unexpected bill from an out-of-network provider.
Learn more about Out-of-Network Liability and Balance Billing.
Yes. You may submit a claim when a provider does not submit one on your behalf.
Claims must be submitted within 12 months or 365 days of the date of service. You must fill out a Subscriber Reimbursement Medical Claim Form. When submitting, include billing statements, your member number and any other relevant documents.
Mail or fax completed forms to:
Group Health Cooperative of South Central Wisconsin
Attn: Claims Department
PO Box 44971
Madison, WI 53744-4971
Fax: (608) 828-4856
For help submitting a claim, contact Member Services at (608) 828-4853 or (800) 605-4327
Learn more about submitting a claim.
A grace period is a limited period during which coverage may remain active even though a premium payment is overdue.
Depending on your plan:
- Claims may be temporarily held while payment is outstanding.
- Pharmacy claims may be denied during certain portions of a grace period.
- Coverage may be terminated when the full outstanding premium is not paid before the grace period ends.
- You may become responsible for claims that were held or denied.
Because the rules vary by plan, contact Premium Billing at (608) 251-4156 ext. 4587 as soon as possible when you are unable to make a payment by its due date.
Learn more about premium payment grace periods and claims pending.
A retroactive denial occurs when GHC-SCW reverses payment of a previously paid claim. The member may then become responsible for the cost.
This may occur in certain situations, including when a member is later determined not to have been eligible for coverage on the date services were received. Paying premiums on time can help prevent some retroactive denials.
You may request a refund when you believe you have overpaid your premium.
Contact GHC-SCW Premium Billing at (608) 251-4156, ext. 4587. Additional information may be required to confirm the overpayment and refund amount.
Prior authorization requests are generally reviewed within the following timeframes:
- 24 hours: Concurrent review when you are actively receiving a service
- 72 hours: Urgent or emergent elective requests
- 15 days: Planned, non-urgent elective requests
- 30 days: Retrospective review of services or treatments already received
The timeframe begins after GHC-SCW receives the information needed to review the request.
Learn more about Medical Necessity, Prior Authorization Timeframes and Member Responsibilities.
Your provider or authorized representative may request a formulary exception when you need a medication that is not included on your plan’s drug list.
Standard exception requests are generally reviewed within 72 hours. Expedited requests are generally reviewed within 24 hours.
To request a form or ask questions, contact GHC-SCW Pharmacy Administration at (608) 828-4811.
Learn more about Prescription Prior Authorization and Exceptions.
An Explanation of Benefits, commonly called an EOB, explains:
- The health care services that were billed
- The amount GHC-SCW paid
- Discounts or adjustments
- The amount you may be responsible for paying
An EOB is not a bill. GHC-SCW sends an EOB when there is an amount listed as patient responsibility.
Learn how to read your EOB.
Coordination of Benefits applies when you are covered by more than one health plan. It determines which plan pays first and how the plans work together to process your claims.
For assistance, contact the GHC-SCW Claims and Coordination of Benefits Department at (608) 251-4138.
To view the QHP Plan Data for the 2025 calendar year (1/1/2025 – 12/31/2025) please visit the complete transparency information page.
Machine Readable Files
The United States Departments of Health and Human Services (HHS), Labor and Treasury issued a Final Rule entitled Transparency in Coverage (the Final Rule) on November 12, 2020. The Final Rule applies to non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets. The Final Rule requires that plans and issuers post publicly available machine-readable files.
Additional information and resources regarding the Transparency in Coverage Final Rule can be found here:
- Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F)
- Transparency in Coverage Final Rule
- CMS Transparency in Coverage Website
- CMS Transparency in Coverage Resources
File Format
GHC-SCW will publish machine-readable files in the JSON format. File Schema information is available on github.com: github.com/CMSgov/price-transparency-guide.
Accessing Files
GHC-SCW produces and posts the required machine-readable files on GHC-SCW’s public website for all fully-insured groups. Files are located at mrf.azureedge.net.
Files are publicly-accessible and free of charge. No user account, password, credential or identifying information is required to access the files.
Groups may link to GHC-SCW’s public website, ghcscw.com/transparency-in-coverage and or mrf.azureedge.net or download and post the files on their own site.
Files will be released every month and will be stamped with the latest file update date. The updated file(s) will also replace the previous file. Pricing included in data contained in posted machine-readable files is accurate as of the date it is extracted but may change before the next update of the files.
To submit questions or technical support requests related to machine-readable files, please email MRF@ghcscw.com.
Identifying Applicable Files
Negotiated Rates Files: The Negotiated Rates Files utilize “Representative Groups”. Use the Index File (YYYY-MM-DD_ghc_index.json) to identify the appropriate Negotiated Rates File. Reference the file schema for details on how to use the JSON Index File. File Schema information is available on github.com: github.com/CMSgov/price-transparency-guide. To find the applicable Negotiated Rate File in the Index File, you will need your group number(s). If you need assistance identifying your group number(s) for the Index, refer to your premium billing invoice or contact the GHC-SCW Enrollment Department at (608) 251-4138.
Note: Allowed Amount Files are generated regardless of whether the group has met applicable claims thresholds during the look-back period. In the event the claims threshold was not met, the group specific Allowed Amount File will be empty.
Disclaimer
Pricing data in posted machine-readable files is not a guarantee of payment and may not match amounts that appear on final documentation after claims are fully processed.
Machine-readable files may include NPIs and/or TINs. You are encouraged to apply for a new TIN if you presently use an SSN as your TIN.
Contact Member Services when you:
- Are unsure whether a provider is in your network
- Receive an unexpected medical bill
- Need help submitting a claim
- Have questions about a denied claim
- Need help understanding your benefits or financial responsibility
Member Services
Local: (608) 828-4853
Toll-free: (800) 605-4327