Prior authorization is the urgent or non-urgent authorization of a requested service prior to receiving the service. The Plan determines approval for prior authorization based on appropriateness of care and service and existence of coverage.
Please see below to learn more about the prior authorization process and what services require prior authorization.
How to Prior Authorize
All requests for certification are to be made by you or your practitioner’s office at least three (3) working days prior to the scheduled admission or requested service. In the event that health care services need to be provided within less than three (3) working days, you should contact the Utilization Management Department to request an expedited review.
To prior authorize, the Health Plan needs the following information:
- Name and ID# for the member requesting services
- Services being requested and the date those services are scheduled (if applicable)
- Specific information related to the member’s condition (if applicable – required for review against standard medical criteria)
The Utilization Management Department will review your medical request against standard criteria. The Utilization Management Department is available between the hours of 8:00am and 5:00pm Central Standard Time, Monday through Friday, by calling our toll-free number 1-800-805-7938 or (605) 328-6807. After hours you may leave a message on the confidential voice mail of the Utilization Management Department and someone will return your call. You may also fax the Plan at (605) 328-6813.
The Member is ultimately responsible for obtaining prior authorization from the Utilization Management Department. However, information provided by the Practitioner’s and/or Provider’s office also satisfies this requirement.
For additional information on the prior authorization process, please refer to your Policy or call our Utilization Management Department at 1-800-805-7938 or (605) 328-6807.
What Services Require Prior Authorization
Prior authorization is the urgent or non-urgent authorization of a requested service prior to receiving the service. Prior authorization is designed to facilitate early identification of the treatment plan to ensure medical management and available resources are provided throughout an episode of care. The Member is ultimately responsible for obtaining prior authorization from the Utilization Management Department in order to receive in-network coverage. However, information provided by the provider’s office will also satisfy this requirement. For additional information on prior authorization, please refer to your Policy or call our Utilization Management Department at 1-800-805-7938 or (605)328-6807.
The following are services that require prior authorization. To prior authorize a service, please call our Utilization Management Department between the hours of 8:00a.m. and 5:00p.m. Central Time, Monday through Friday, at 1-800-805-7938 or (605)328-6807. After hours you may leave a message on the confidential voice mail of the Utilization Management Department and someone will return your call. You can also fax the Plan at (605) 328-6813.
The following are services that require prior authorization for South Dakota, Iowa and Minnesota members:
- Inpatient Hospital admissions including admissions for medical, surgical, neonatal intensive care nursery, mental health and chemical dependency services;
- Selected Outpatient Procedures;
- Home Health, Hospice and Home IV therapy services;
- Select Durable Medical Equipment (DME). (See DME requiring Certification in your Policy);
- Skilled nursing and sub-acute care;
- Transplant Services;
- Referrals to Non-Participating Providers which are recommended by Participating Providers. Certification is required for the purposes of receiving In-Network coverage only. If Certification is not obtained for referrals to Non-Participating Providers, the services will be covered at the Reduced Payment Level. Certification does not apply to services that are provided by Non-Participating Providers as a result of a lack of appropriate access to Participating Providers as described in your Policy;
- Morbid obesity surgery; and
- Accupuncture when requesting more than 12 sessions/visits (for Minnesota Members only).
Pharmacy Information - Link to Express Scripts, Inc. Sanford Health Plan Members with pharmacy benefits may review their pharmacy coverage, find drug information and locate pharmacies.
Attention Members: Please refer to your Policy for details about requesting an exception to the formulary. Your Policy also includes state mandated formulary benefits and quantity limits.
Generic Medication Information
Walgreens Remains a Non-Participating Pharmacy in the Sanford Health Plan Pharmacy Network
Sanford Health Plan contracts with Express Scripts Inc. as its vendor for processing and paying pharmacy claims and accessing its network of 60,000 pharmacies nationwide. Last fall Walgreens made the business decision to no longer partner with Express Scripts due to payment disputes. They also participated in a widespread disparaging public campaign that was detrimental to our partner, Express Scripts, and caused undue concern with our clients and members while the termination was underway.
During this past year, Express Scripts and Walgreens came to an agreement on their contractual disputes. However, Sanford Health Plan’s priority is to maintain relationships with committed partners whose primary objective is to take care of our members. Those pharmacies that remained in the network last year during the Walgreens dispute were committed to our members and the communities we serve and specifically provided programs to meet our members’ needs (fills and transfers) in a courteous and easy manner. Consequently, Sanford Health Plan has made the decision not to add Walgreens back into our network. We have ensured that there is more than adequate access to pharmacies who value our business and our members.
An analysis of our current utilization provided the following talking points in support of our decision:
1. Sanford Health Plan’s goal is to ensure our members continue to have access to participating pharmacies. Analysis of our membership data shows that even without Walgreens in our network, each of our members still will have access to another participating pharmacy within 2-3 miles of their place of residence.
2. More than 98% of our members have access to another participating pharmacy within one mile of their residence and over 99% have access within two miles.
3. Sanford Health Plan worked closely with our pharmacies and members to transfer their prescriptions from a Walgreens pharmacy to a new participating pharmacy of their choice earlier this year.
4. The copayment or coinsurance amounts our members pay for their pharmacy benefit remain unchanged when members receive drugs from a participating pharmacy.
Sanford Health Plan Members who choose to begin receiving their prescription drugs from a Walgreens pharmacy will not have insurance coverage to help pay for the cost of their drugs. If you have questions or concerns, please contact our Utilization Management Department at (800) 805-7938.
What If Your Prescription Drug Is Not On The Formulary?
Sanford Health Plan uses a Formulary to help you save money and help control the costs of healthcare. The Formulary is a list of medications that are most effective for the treatment of a disease according to the clinical judgment of the physicians, healthcare providers, and pharmacists who helped us develop the Formulary. Of course, not all drugs are included in the formulary. However, we understand that sometimes exceptions must be made. Under the following circumstances, Sanford Health Plan will provide you with a Medication Request Form if you feel an exception must be made to our Formulary.
- You or your physician feel it's medically necessary to allow you to take a drug that is not listed on our formulary; or
- You have tried our Step Therapy program and cannot tolerate the side effects or the use of the Step Therapy drugs are counter-indicated and you would like authorization for coverage of those drugs.
You may fill out a Medication Request form online:
For medication safety, visit www.AHRQ.GOV.
If you have questions, please contact our Health Services Department at 605-328-6807 or toll free at 1-800-805-7938.
Pharmacy Benefits and Formulary
2013 Formulary Changes
2013 South Dakota, North Dakota and Iowa Pharmacy Benefits/Formulary
2013 Minnesota Pharmacy Benefits/Formulary
Covered Generic Oral Contraceptives
Recent Medication Additions/Changes
Androgel – tier 2- PA is required as of 6/1/13
Invokana – tier 2- as of 5/13/13
Liptruzet – tier 2- PA is required as of 6/1/13
The Provider Application attached below is the Sanford Health Plan's initial credentialing application. This application would need to be completed by new providers that have NOT previously been credentialed for Sanford Health Plan.
A recredentialing application is a pre-populated application with the provider's information already completed so all the provider needs to do is update her/his application. This application is sent to the provider by Sanford Credentialing Verification Office six months before her/his recredentialing period is expired.
Sanford Health Plan accepts the below credentialing applications. Please fill out the credentialing application that is most appropriate to you. Sanford Central Verification Office also participates with the Minnesota Credentialing Collaborative, therefore accepts credentialing applications electronically through the site located at www.mncred.org.
For additional credentialing questions please call the Provider Relations Department at 605-328-6877 or 1-800-601-5086.
South Dakota Provider Application
Iowa Provider Application
Minnesota Provider Application (fillable, can be used for all states)
Facility Credentialing Application
Credentialing Policy PR-06
Credentialing Policy PR-10
Sanford Health Plan encourages the use of EDI transactions to increase efficiency and reduce errors. Sanford Health Plan will accept 837 compliant claim transactions meeting our Companion Guide criteria. Companion Guides are available for download below:
Trading Partner Agreement (TPA)
EDI Trading Partners
To discuss direct claim submittal or for general questions please contact:
Please contact these clearinghouse(s) directly for more information on submitting electronic claims via their services.
EFT and 835 ERA
Sanford Health Plan Contracts with Emdeon to Deliver EFT and 835 ERAS!
As changing market dynamics continue to increase the pressure to maximize revenue and profit, providers and healthcare systems are searching for ways to reduce costs while increasing efficiency across the billing cycle. To that end, we are pleased to announce that Sanford Health Plan has arranged for Emdeon to deliver ePayment services, consisting of electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions in the postable 835 format.
Harness the power of electronic remittances
Emdeon provides payer remittance data electronically via Emdeon Payment Manager, which is offered as a complimentary service with EFT enrollment. You will continue to receive paper remittances for 45 days after EFT enrollment. At this time paper remittances will no longer be sent. However, these documents will continue to be available electronically through Payment Manager. With Payment Manager, staff can quickly search, view or print each remittance as needed.
Simple enrollment. Incredible benefits.
We invite you to enroll today to begin taking advantage of electronic payments and remittance statements that may be already available from your other payers (see a full list of payers by visiting the link provided at the end of this letter).
Enrollment for Emdeon ePayment is a fast, one-time process. Simply follow the instructions outlined below to begin receiving electronic payments and remittance advices today!
834 Companion Guide - for Benefit Enrollment and Maintenance
837 Institutional and Professional Companion Guide
837 Dental Companion Guide
myHealthPlan for Providers
On-Line Access to Member Benefits, EOPS, Submit Prior Authorizations and more....
myHealthPlan is Sanford Health Plan's online benefits tool available to Providers. Through this online tool, we are able to offer you more streamlined services and access to information any time of day all at your fingertips. We recognize our provider network is vital to the quality service we promise our members. Therefore, Sanford Health Plan is committed to providing you with the online tools you need to process claims, manage member information and improve your administrative efficiency. Please encourage members of your staff to sign up for an account and begin taking advantage of the benefits myHealthPlan can provide.
With myHealthPlan you will enjoy these features:
- View benefits accumulators for members - deductibles, coinsurance and out-of-pocket expense totals at a glance.
- Verify up to two years of member eligibility information
- View check numbers to track payment - identify if a check has posted or cleared.
- Register under multiple Tax Ids and NPI Numbers - access information for multiple billing entities.
- Email Express Requests to Provider Relations, Member Services and Utilization Management for Prior Authorization requests.
- View Provider Resources including forms, the Manual and its Policies
To register for myHealthPlan click on myHealthPlan. This will transport you to the login page where you can sign up for a Provider account.
If there is anything you would like to see added to myHealthPlan, please let your Provider Relations Representative know or email us at email@example.com
Sanford Health Plan strives to partner with its Practitioners and Providers in providing optimum care for our Plan Members. On this page you will find links to various clinical resources and tools designed to assist Practitioners in practicing evidence-based medicine. Among these resources and tools are quick reference cards to assist in locating participating behavioral health Practitioners, immunization and preventive health guideline information, fact sheets, links to other reputable medical society websites and much more. For more information contact Care Management. Their contact information can be found in the Contact Us section. To view your benefits, claims and much more, use myHealthPlan.
Health Management Programs
Sanford Health Plan offers three health management programs to members. These programs include prevention and condition management initiatives. Members can obtain information on covered benefits by calling Member Services or their provider can complete and return the referral form to Sanford Health Plan. Learn more.
Quality Improvement Activities and Clinical Practice Guidelines
What steps can Sanford Health Plan take to better manage medical conditions such as headaches and asthma? We have implemented several quality improvement activities that can help. Eligible members are identified for quality improvement activities through insurance claims, age/gender or upon request from a member or their practitioner. These activities have empowered many individuals and families in their journey to improved health and better quality of life. Contact Sanford Health Plan Care Management for any questions or concerns at (888) 315-0884, Monday – Friday 8 a.m. to 5 p.m. CST.
Sanford Health Plan is also responsible for adopting and distributing clinical practice guidelines for acute, chronic and behavioral health care services that are relevant to our membership. Clinical practice guidelines are systematically developed statements that help practitioners and members make decisions about appropriate health care for specific clinical circumstances. These guidelines can improve health care and reduce unnecessary variations in practice patterns. Practice guidelines are based on reasonable medical evidence, such as clinical literature and expert consensus. The Plan’s multi-specialty physician committee, the Physician Quality Committee, has reviewed and approved practice guidelines for numerous conditions. Where links are provided, Sanford Health Plan has adopted the clinical practice guidelines exactly as they are written by the respective organizations. If you have any questions or suggestions regarding these guidelines or would like to request a copy, call (800) 601-5086 or (605) 328-6877.
Quality Improvement Program
Sanford Health Plan ("the Plan") and its participating practitioners and providers acknowledge their responsibility to provide high quality care in a cost-effective manner through an ongoing monitoring, evaluation and improvement process. The organized method for monitoring, evaluating, and improving the quality, safety and appropriateness of health care services including behavioral health care to members through related activities and studies is known as the Quality Improvement (QI) program.
The mission of the QI Program is to provide accountability for the quality of health care delivery and service. This is accomplished through the commitment of the Board of Directors and the Physician Quality and the Health Plan Quality Improvement Committees to develop and carry out a Quality Assurance Plan that has a systematic approach to assessing, measuring, defining and resolving medical care, and behavioral health and service issues.
The Plan believes that the only way to achieve continuous quality improvement is to have its entire organization embrace a well defined Quality Improvement Program and Annual Work Plan in their day to day activities.
GOALS AND OBJECTIVES
- Assure high quality of care to all Plan members.
- Continuously monitor and improve the quality and safety of patient care and health delivery services by all practitioners with delineated clinical privileges.
- Continuously monitor and improve behavioral health care through education and collaboration with behavioral health practitioners. This will be accomplished through reporting and analyzing behavioral health related HEDIS measures, the involvement of a behavioral health practitioner on the Physician Quality Committee to assist in decisions regarding behavioral health related utilization management (UM) issues and QI activities, and the collaboration with area behavioral health practitioners to improve the continuity and coordination of the behavioral health care that Plan members receive.
- Oversee and assess medical care systems, processes and outcomes.
- Oversee and assess components of health service delivery.
- Oversee the credentialing and recredentialing of all health care practitioners and providers.
- Implement standards of care and practice guidelines as recognized by national specialty academics, nationally recognized authorities, and standards developed by the Physician Quality Committee. Communicate standards and guidelines to practitioners and providers, when appropriate.
- Review and/or update criteria, guidelines and standards of care and services at least annually based upon UM and QI activities and results.
- Monitor compliance with standards of care and services.
- Monitor compliance with Medical Record standards.
- Implement improvement interventions as necessary.
- Monitor member and practitioner/provider complaints and appeals, the reasons for the complaint and appeal, and the Plan’s resolution turnaround time.
- Develop and maintain a monitoring system to detect trends.
- Assess effectiveness of improvement interventions.
- Establish and maintain a preventive process that identifies potential risk management issues.
- Conduct special reviews as specified by major employer groups and insured clients.
- Recognize and evaluate new health care services, technologies, procedures, and pharmacological treatments, as well as their application for the population served.
- Demonstrate a commitment to improving safe clinical practice by fostering a supportive environment to help practitioners and providers improve the safety of their practices. This may be accomplished through the distribution of information to practitioners to assist in facilitating a safer clinical environment.
- Distribute information to members to improve their knowledge about prevention of illness as it relates to their own healthcare. Also to distribute information regarding clinical safety to facilitate informed decision making.
- Address patient safety issues, potential disparities in clinical care and service and complex health needs (i.e., physical or developmental disabilities, severe mental illness, multiple chronic conditions) in existing QI activities and disease management programs through prevention and educational activities. These needs are also addressed in the complex case management program, for those members identified as eligible.
- Cultural and linguistic needs of the membership are assessed by analyzing census data, CAHPS demographic data and HEDIS data collected on race/ethnicity of the member population. An assessment of the practitioner network is completed based on these needs as well. Educational materials are provided in other languages on our website for members.
- QI encompasses the entire delivery system, including, but not limited to, hospital care, ambulatory care, ancillary services, emergency services, behavioral health services, preventive services, vision services, pharmacy, dental services, home health care, hospice care and extended care facilities.
- QI addresses both the quality and safety of clinical care and the quality of non-clinical aspects of service, including availability, accessibility, coordination and continuity of care, including referrals, case management, discharge planning, prior authorizations, practitioner and provider reimbursements, and complaints.
- The medical delivery system is monitored for both quality and utilization activities. Both over-utilization and under-utilization are addressed.
- Departments that support and may be included in the QI process are Care Management, Utilization Management, Worksite Wellness, Information Technology, Provider & Payor Relations, Client Services/Marketing and Member Services.
- Satisfaction surveys are conducted to obtain information pertaining to member and practitioner/provider perceptions of Plan policy and procedure.
- The Plan provides for ongoing Internal Peer Review activities to ensure continuous quality improvement and will solicit the assistance of External Peer Review Organizations every two years to collect benchmark data to evaluate the Plan’s overall performance.
- The Plan will achieve any performance levels as established by CMS, State, or NCQA with respect to standard measures. Performance measures may be contained in standardized national data collection and reporting instruments such as HEDIS and CAHPS and/or be CMS, State or NCQA specific.
HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare healthcare quality. To demonstrate our commitment to providing the highest quality of care and service, Sanford Health Plan would like to present our HEDIS report along with the quality improvement activities and disease management programs implemented by the Plan. This data provides you - our customer - with the information you need to judge our success in meeting our goals in various performance areas. The HEDIS measures, which are reported on an annual basis, are divided into domains that all reflect different aspects of care. The results are presented to you in comparison to national benchmarks. The HEDIS results are also compared to the Healthy People 2020 goals, where available. Healthy People 2020 is a set of 10-year health objectives for the United States aimed at health promotion and disease prevention initiatives. These goals were developed by the U.S. Department of Health and Human Services with the input of public health and prevention experts and a wide range of government officials and organizations.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Sanford Health Plan's 2012 HEDIS Report.
View our JCodes requiring NDC Number
2012 Flu Shot Roster
Medication Request Form
Minnesota Medication Request Form
Provider Change Form
Diabetes Eye Exam Consult Form
My Health Worksheet (fillable)
Symptom Help for Viruses
ATTENTION EYE CARE PRACTITIONERS: Sanford Health Plan is concerned with ensuring the continuity and coordination of care of our members with diabetes. In order to improve the lines of communication between our eye care professionals and our member’s primary diabetes care provider, we recommend that your clinic utilize this form in providing your patient’s primary diabetes care provider with information related to their diabetic eye exams.
All Providers (both participating and non-participating) submitting claims to Sanford Health Plan must complete a W-9 Form. You may fax this form to Sanford Health Plan Provider Relations Department at 605-328-7224.
Medication Request Form for Providers
Click here for the form.