Prior Authorizations

Prior authorization (certification) is the urgent or non-urgent authorization of a requested service prior to receiving the service. Prior authorization (or precertification/pre-service decisions) 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 Plan determines approval for prior authorization based on appropriateness of care and service and existence of coverage. The Plan does not compensate practitioners and/or providers or other individuals conducting utilization review for issuing denials of coverage or service care. Any financial incentives offered to Utilization Management decision makers do not encourage decisions that result in underutilization and do not encourage denials of coverage or service.

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 the Provider Manual on our website at www.sanfordhealthplan.com or call our Utilization Management Department at 1-800-805-7938 or (605)328-6807.