CoOportunity Health is required by state and federal regulations to provide newly enrolled members with important information about health plan policies and practices. Please take a few minutes to review the topics below so that you and your family understand your rights and responsibilities as a member, and know what to expect from CoOportunity Health. You may also download this convenient booklet.
How to Access Important Information Online
You may obtain personal information and documents specific to your insurance coverage and benefits online. First, you’ll need to register for our secure member website for personalized eTools access.
Notice of Privacy Practices
It is important that you understand how CoOportunity Health protects the privacy of our members including personal health information. You may review CoOportunity’s Notice of Privacy Practice to find out how your health or financial information may be used and disclosed.
We encourage you to contact us with any questions or concerns about our Privacy Practices or your rights. Call Member Services at 1.888.324.2064. You may also reach our Privacy Officer at 1.855.977.7161, by email at [email protected], or by mail at: Privacy Officer, CoOportunity Health, 2700 Westown Parkway, Suite 345, West Des Moines, Iowa 50266-1411.
Member Rights & Responsibilities
As a CoOportunity Health member, you are entitled to certain rights and responsibilities. Similarly, you have a responsibility to participate in your healthcare. A good partnership between you, your healthcare providers, and CoOportunity Health will enhance your ability to receive the maximum benefit from your health plan.
Claims Appeal & External Review
You have the right to appeal any decision that denies payment on your claim or your request for coverage of a healthcare service or treatment. If your claim was denied due to missing or incomplete information, you or your healthcare provider may resubmit the claim with the necessary information to complete the claim. Read more specifics about the claims appeal and external review process.
How We Pay Providers
We use several different reimbursement arrangements – all designed to provide affordable care for our members while encouraging quality care. Learn about our various provider reimbursement types.
Coverage for New Treatments, Devices, Pharmaceuticals, Procedures & Technologies
CoOportunity Health generally extends health plan coverage to all procedures, drugs, devices and technologies that have been demonstrated to be safe, effective and medically necessary unless an equally safe, effective, less costly alternative exists. Read details on how we determine coverage.
Quality Improvement Program & Evaluation
CoOportunity Health’s goal is to be the best health plan, period. Our aim is to ensure our members have access to excellent clinical care, unmatched levels of service, all at affordable prices. To ensure we are meeting these objectives we measure our progress every step of the way through our Quality Improvement (QI) Program and Evaluation. Follow our progress by reviewing the QI Program Evaluation posted on our website following the completion of each calendar year of service or requesting a copy of the CoOportunity Health QI Program Evaluation by contacting Member Services. You may download the CoOportunity Health Quality Improvement Program Description or request a copy by contacting Member Services at 1.888.324.2064 (TTY: 1.888.850.4762).
National Committee for Quality Assurance (NCQA)
To demonstrate CoOportunity Health’s commitment to quality, we participate in the National Committee for Quality Assurance (NCQA) accreditation process.
NCQA is a private, not-for-profit organization dedicated to improving health care quality. NCQA is committed to providing health care quality information through the web and the media in order to help consumers, employers and others make more informed health care choices.
We are pleased to announce that the NCQA Review Oversight Committee has awarded CoOportunity Health the Interim Health Plan Evaluation rating.
Read More
Affirmative Statement About Incentives
It is the policy of CoOportunity Health that utilization review decisions are made based only on appropriateness of care, service and existence of coverage. Financial incentives, if any, that are offered by CoOportunity Health (or any entity that contracts with CoOportunity Health to provide utilization management services) to individuals or entities involved in making utilization management decisions will not encourage decisions that result in underutilization or inappropriate restrictions of care. This means that CoOportunity Health and entities contracting with CoOportunity Health to provide utilization management services will not specifically reward, hire, promote or terminate practitioners or other individuals conducting utilization review, for issuing denials of coverage or services. Rather, financial incentives will be designed to encourage appropriate utilization and discourage underutilization.
Clinical & Preventive Care Guidelines
Healthcare guidelines identify best practices for preventing or treating a health condition. CoOportunity Health promotes and encourages the knowledge and use of these guidelines by our network practitioners. We have adopted the guidelines recommended by the Institute of Clinical Systems Improvement (ICSI) and the guidelines of the U.S. Preventive Services Taskforce for use in administering our health plans.
Summary of Utilization Management Programs
CoOportunity Health’s utilization management program helps ensure our members receive effective, accessible and high quality healthcare. The criteria and methods used by this program are based on the most up-to-date medical evidence to evaluate appropriate levels of care and treatment. Our program includes activities to reduce the underuse, overuse, and misuse of healthcare services. These activities include:
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Prior authorization of select tests, treatments, services, medications and devices. Review the most up-to-date list of services requiring prior authorization .
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The CareCheck® prior authorization program to coordinate out-of-network hospitalizations and certain services. Member must call CareCheck at 1.800.316.9807 to receive maximum benefits when using out-of-network providers.
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Inpatient concurrent review and care coordination to support timely care and ensure a safe and timely transition from the hospital.
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Outpatient case and disease management to provide care coordination and between-visit support of the patient’s care plan.
For more information, contact 1.888.324.2064 (TDD/TTY: 1.888.850.4762), Monday through Friday from 7 a.m. to 6 p.m. Language assistance is available.
Report Fraud, Waste & Abuse
CoOportunity Health is committed to preventing, detecting, and reporting fraud, waste and abuse. We all need to help with this important effort. There are several simple steps you can take to prevent and detect fraud, waste and abuse, including knowing the signs and asking questions when something looks or feels suspicious, and reporting your concerns. Some examples of fraud, waste and abuse include being billed for services or treatments you did not receive, using another person’s insurance card or identity to receive healthcare services, or forging or altering a prescription to receive a different medication, dose or amount than the prescribing practitioner intended. If you have questions or suspect fraudulent activity, call Member Services at 1.888.324.2064. Your call will be kept confidential.
The Women’s Health and Cancer Rights Act
The Women’s Health and Cancer Rights Act of 1998 is a federal law that requires health plans to cover breast reconstruction following a mastectomy. The law requires coverage for reconstruction of the affected breast after mastectomy surgery, for surgery and reconstruction of the other breast, for symmetry, and for prostheses and physical complications at all stages of the mastectomy, including lymphedemas. The need for these services should be discussed with your physician. Breast reconstruction is covered under your medical/surgical benefits and is subject to any deductible and coinsurance limitations as described in your member contract or summary plan description.
Language Assistance
CoOportunity Health is committed to providing language assistance services for all members with limited proficiency in English or whose disabilities may require special communication technologies. Member Services provides staff interpreters for Spanish speaking members. For members who speak another language, the Language Line is available at no cost for third-party interpretation. The Language Line offers interpreters for a variety of different languages. The Member Services staff also can assist you in locating healthcare practitioners in our network who can communicate with you in the language(s) you or your family speak.
Getting Care When Traveling
When traveling or working outside of CoOportunity Health’s primary service areas, members enrolled in the CoOportunity Premier and Choice UIHA plans can receive care from in-network providers through our national provider networks – the PHCS Network and the MultiPlan network. Search the national provider directory or call Member Services at 1.888.324.2064 to find a provider. CoOportunity Health members enrolled in Preferred UIHA plans do not have any nonemergency out-of-network benefits. If members receive nonemergency services from an out-of-network provider or facility, members are responsible for the entire billed charge. All emergency care received by CoOportunity Health members is treated as in-network care, even if it is provided at an out-of-network facility.
Obtaining Care After Hours
Sometimes you may need to seek care when your doctor’s office is closed. If it is after hours, the regular office telephone number should provide options for you to speak with an on-call provider to determine appropriate next steps.
You should call 9-1-1 or seek care from an emergency department or urgent care facility if it is a medical emergency in which treatment is needed immediately to prevent a serious decline in your health if care is delayed until the office is open.
Registered nurses are also available around-the-clock by calling CareLine 24/7 at 1.888.324.2064. The nurses can provide help for:
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Home treatment advice
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Medication questions
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Urgent healthcare questions
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Pregnancy questions
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New baby questions
Submitting Claims
When you receive care from an in-network or contracting provider, that provider will submit the claim to CoOportunity Health for you.
Should you receive care from an out-of-network provider, you may have to submit the claim. Use this claim form to submit non-network provider claims to CoOportunity Health. You can also call Member Services at 1.888.324.2064 to receive a copy of the claim form.
Send the claim form along with an itemized bill that includes:
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The date and type of service
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Provider name
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Charges for covered service
Send the information to:
CoOportunity Health
P.O Box 38
Minneapolis, MN 55440-9984
Claims must be submitted within 365 days after the date the services were received.
Voicing Complaints
We hope you’re delighted with CoOportunity Health. But if you have a complaint with any of the following, you can share that feedback with Member Services:
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Enrollment process
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Care experience from your provider
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Claims payment process
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Other concerns
Please write or call to share your feedback:
CoOportunity Health
Member Services Department
8170 33rd Avenue South
P.O. Box 1309
Minneapolis, MN 55440-1309
1.888.324.2064
Emergency Care
If you believe you are having a medical emergency and immediate care is necessary to prevent a serious decline in your health or your life is in danger, you should call 9-1-1 or seek care from the nearest hospital emergency department.
All CoOportunity Health plans include benefits for emergency services. You do not need to receive approval from CoOportunity Health before receiving emergency care.