Transition to GHC-SCW
Thank you for choosing Group Health Cooperative of South Central Wisconsin (GHC-SCW) as your new health care and insurance partner!
We want to make sure all new members enjoy an easy transition when joining the Cooperative. Our Care Management and Member Services Teams are available to answer any questions you may have.
You have questions; we have answers.
For questions about providers, your coverage, clinic locations, copays, coinsurance and more, call Member Services at (608) 828-4853 or (800) 605-4327 and request Member Services.
For questions about transitioning your care to GHC-SCW, call Care Management at (608) 257-5294 or (800) 605-4327; Ext. 4514.
Steps to Transition Your Care
For the smoothest transition possible, we recommend following these steps once you’ve applied for coverage:
1. Select a Primary Care Provider.
If you haven’t already done so in your enrollment application, pick a Primary Care Provider. They will be your partner, working alongside you to manage your care. Find a list of available providers through our Find A Provider search below. You may call Member Services to switch providers at any time.
2. Complete a Transition of Care Form.
This form should be completed for each person who needs help transitioning their care to GHC-SCW. The form is for:
- People under active treatment with a specialist (like cardiology, oncology, behavioral health therapist, etc.) and have appointments scheduled within the first 90 days of starting GHC-SCW insurance. Note: Primary Care visits do not qualify for transition of care.
- People scheduled for surgery before your GHC-SCW start date who will need a follow up to that surgery within the first 90 days of starting with GHC-SCW.
- People scheduled for an eligible surgery, procedure, advanced imaging, or infusion within the first 90 days of starting with GHC-SCW.
- People who are currently pregnant.
- People who use durable medical equipment.
- People who take prescription medications.
3. Send your Transition of Care Form to the GHC-SCW Care Management Department.
Submit the completed form in one of four ways:
1. Fill out and submit an online transition of care form.
2. Download, fill out, then fax your completed transition of care form PDF to: (608) 733-6316.
3. Download, fill out, then mail your completed transition of care form PDF to:
GHC-SCW Care Management
1265 John Q Hammons Drive
Madison, WI 53717
4. Get enough of your medication refills.
Talk to your current medical providers before you switch to GHC-SCW coverage to make sure you have enough medication refills on file so that you don’t miss any doses before you can see your new Primary Care Provider.
5. Schedule a new member appointment.
Two weeks after your application for insurance is approved, call GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327 to get your new member number. With that member number in hand, call your new primary care clinic and schedule a new member appointment after your start date.
You’ll use this appointment to talk to your new provider about medication refills, medical history, concerns and specialists that you see (to get new referrals).
Frequently Asked Questions About Transitioning Your Care
We use Transition of Care to talk about the process of people under active treatment for a medical or behavioral health condition with an out-of-network provider during their transition to GHC-SCW. People who qualify are currently under the active treatment of a specialist and have an appointment(s), surgery, procedure, infusion, or imaging already scheduled within the first 90 days of starting GHC-SCW insurance, people who are pregnant, people using durable medical equipment, or people taking prescription medications. Those services must also be a covered benefit and meet criteria with your GHC-SCW plan.
Active treatment means you’ve seen a provider or therapist for treatment of a medical or behavioral health condition at least twice within the past three months.
The Transition of Care process is different from your annual appointments or new appointments made for a medical or behavioral health condition. When you start your GHC-SCW coverage, you’ll establish appointments with your new Primary Care Provider for those things.
No, you won’t be able to see your provider if they’re out-of-network under your new GHC-SCW coverage. PCPs don’t qualify for this Transition of Care process so please see them before your new GHC-SCW coverage begins.
As soon as you can before you start with GHC-SCW insurance. This will give our team time to look over it and reach out to you to help before your coverage starts.
You will only be assigned a PCP if you do not put one on your enrollment form. They will be assigned to you based on where you live. You can change them at any time by calling Member Services at (608) 828-4853 or (800) 605-4327.
You can call GHC-SCW Member Services at (608) 828-4853 or (800) 605-4327 with any questions regarding plan providers, covered services, benefit coverage, location of clinics, co-pays and coinsurance.
If you are less than 28 weeks pregnant at the start of GHC-SCW coverage and seeing an out-of-network provider, you will need to transition your care to a new in-network OB/GYN provider. If you are 28 weeks or more at the start of coverage and seeing an out of network provider, you may stay with your current OB/GYN provider and delivery hospital.
To see if your behavioral health provider is contracted with GHC-SCW, visit our Behavioral Health provider search. If they are out-of-network, you may be allowed transitional visits for the first 90 days after starting your coverage. Contact Care Management at (608) 257-5294 or (800) 605-4327 Ext. 4514 with questions.
For a CPAP/BiPAP, if you have completed more than 50% of rental (For example: 7 out of 12 months), GHC-SCW will allow you to finish with your current out-of-network DME provider. Any other DME and/or supplies need to transition to an in-network provider within 90 days.
Contact your specialist or provider that orders the medication. They will need to submit a Prior Authorization to either GHC-SCW or Magellan for the medication. The list can be found here. Magellan usually reviews these in one to two days.
If your surgery is scheduled with an out-of-network provider and is after the first 90 days of beginning GHC-SCW insurance, you will need to have the surgery completed with an in-network provider.
If your surgery is with an in-network provider and is scheduled past the 90-day transition of care timeframe, contact your specialist. They need to send a Prior Authorization to GHC-SCW for your procedure.
Transition of care limitations may apply with elective procedures.
Your first post-op visit after a major surgery is covered under a 90-day global fee where you will not be billed additional fees.
If more than 90 days and the surgeon is out-of-network, you will need to schedule that visit with an in-network provider.
Once we receive a prior authorization form, we have up to 15 calendar days to process routine requests. Most requests are handled within a week of receiving the prior authorization form.
If your current provider and new provider both use EPIC charting, then your new provider can easily load your medical records into their EPIC system and you don’t have to do anything else.
UW Health, SSM Health Dean Medical Group, UnityPoint Health – Meriter, Divine Savior, Upland Hills Health, Fort HealthCare, Mercy Healthcare, Southwest Health all use EPIC charting.
If your previous provider did not use EPIC charting, you will need to contact that health system and request your medical records to be faxed or sent to GHC-SCW.
Learn more about transferring your medical records here.