Common Ground Healthcare Cooperative claim denials in Wisconsin: the federal figures
Common Ground Healthcare Cooperative denied 16.5% of in-network claims in Wisconsin — 465,910 claims out of 2,820,526. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Common Ground Healthcare Cooperative) | 262 | 31.7% |
| External review (independent) | — | — |
What Common Ground Healthcare Cooperative denies most
The most common denial reason recorded for Common Ground Healthcare Cooperative plans in Wisconsin is administrative reason. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Administrative reason | 155,507 | 32.3% |
| Service excluded from the plan | 150,121 | 31.2% |
| Other reasons | 82,025 | 17% |
| Provider out of network | 35,480 | 7.4% |
| Referral required | 34,417 | 7.1% |
| Not medically necessary | 15,725 | 3.3% |
| Member not covered | 7,167 | 1.5% |
| Benefit limit reached | 1,442 | 0.3% |
| Experimental or investigational | 14 | 0% |
What to do if Common Ground Healthcare Cooperative denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. Common Ground Healthcare Cooperative overturned 31.7% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Common Ground Healthcare Cooperative. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your Common Ground Healthcare Cooperative appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is Common Ground Healthcare Cooperative's denial rate high?
16.5% against a national average of 16% across the plans in this dataset. It is above average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can Common Ground Healthcare Cooperative ignore the external decision?
No. External review decisions are binding on the plan.