Prior Authorization Network Exception Process

Members seeking out-of-network care must have an approved prior authorization for network exception for claims to process at an in-network benefit level.

The prior authorization for network exception, submitted by the referring provider, details why care cannot be provided within the network. Sanford Health Plan’s team of medical experts reviews the requests for (1) medical necessity and then (2) if the request can be fulfilled by an in-network provider or facility.

Based on this information, the team either approves or denies the request, notifying both the member and provider of the determination in writing. If the request is denied, members will also receive information on how to appeal the decision. All out-of-network referrals, no matter the referral source, must go through this process.

If the request is denied because an in-network provider is available to perform the needed service, members can still choose to proceed with care at the out-of-network provider.

However, in this scenario, benefits process according to the particulars of the member’s specific plan. These are the two options:

• The service is processed as an out-of-network benefit subject to out-of-network cost shares; this happens when the member has out-of-network benefits AND the provider is within the service area outlined in the member’s plan.
• The service is a denied benefit; this occurs when the member does not have out-of-network benefits OR the provider is located outside the service area detailed in the member’s plan.

Members can verify their network and view in-network providers by checking the online provider directory or by calling customer service at (800) 752-5863.

Prior Authorization for Network Exception FAQs

What does medical necessity mean?

When the Sanford Health Plan (SHP) team reviews a request for medical necessity, these are the key questions they ask:

• Is the specific treatment, test, consultation or service appropriate for managing the member’s health condition?
• Does it follow accepted medical practice guidelines?
• Is it elective or based on preference?
• Is it an essential service genuinely needed for the member’s care?

What type of information should the provider include in the network exception submission?

The referring provider must provide as much detail as possible as to why care cannot be provided within our network before the request can be processed. All out-of-network referrals, no matter the referral source, must go through this process.

What are the key areas Sanford Health Plan reviews in their determination for network exceptions?

Once the information is submitted, SHP reviews the request for (1) medical necessity and then (2) if the request can be fulfilled by an in-network provider or facility. Additional factors including how far the member would need to travel to access care (mileage) and wait times are also reviewed as a part of this process. Based on this information, the team either approves or denies the request, notifying both the member and provider of the determination in writing. If the request is denied, members will also receive information on how to appeal the decision.

Are members responsible for completing the prior authorization for network exception forms?

No. The referring provider will complete and submit the request. However, members can request a copy of the completed form.

What can I do if my request is denied?

Please follow the directions outlined in the written denial or call our customer service team at (800) 752-5863.

Is the prior authorization request for a network exception different than a prior authorization for a service?

No, the request goes through the same review process.