Medical Policies

Browse Align powered by Sanford Health Plan’s medical policies below.

2025 Medical Policies

Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

  • Medicare national coverage determinations (NCDs)
  • Local coverage determinations (LCDs)
  • The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, Sanford Health Plan uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These Sanford Health Plan coverage summaries apply to Align powered by Sanford Health Plan Medicare Advantage plans.

Sanford Health Plan uses vendor guidelines for certain products to support utilization management review of certain services.

Access MCG care guidelines online using the link below. You will be asked to check the Terms and Conditions box, select Accept and Proceed, and then enter your username and contact information. After completing these steps, you will receive an access code via your preferred method.

Access Coverage Policies

2026 Medical Policies

Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

  • Medicare national coverage determinations (NCDs)
  • Local coverage determinations (LCDs)
  • The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, Sanford Health Plan uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These Sanford Health Plan coverage summaries apply to Align powered by Sanford Health Plan Medicare Advantage plans.

Sanford Health Plan uses vendor guidelines for certain products to support utilization management review of certain services.

 

InterQual® Transparency Tool

The InterQual® Transparency Tool can be used as part of the utilization management process to provide enhanced clinical detail during the review process. This tool allows for consideration of an individual’s severity of illness, comorbidities and complications during the review process in real-time. To learn more visit Change Healthcare and follow these steps:

  1. Create a One Healthcare ID.
  2. Once logged in, you can select the subsets from the drop-down menu.
  3. Under product, select the appropriate subsets: LOC: Acute Pediatric, CP: Imaging, etc.

Sanford Health Plan and Sanford Health Plan of Minnesota have HMO and PPO plans with a Medicare contract. Sanford Health Plan D-SNPs have contracts with State Medicaid programs. Sanford Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, or any other classification


CMS ID Number: Y0128_ HP-9847-SHPMAWebsite_10-25_M_ND_SD_IA, H3186_SHPMAWebsite_PY2025_MN H8967_DSNPWebsite_PY2025_ND

 



Last Updated On: 12.29.25 at 10:00 AM