To help minimize cost, Members should request pre-approval (authorization) from Sanford Health Plan when they would like to receive routine covered services from out-of-network providers.
If prior-approval is not requested and approved, members are subject to the out-of-network deductibles, coinsurance, and maximum out-of-pocket benefits. If the Member does not have out-of-network benefits, they may be responsible for the entire amount billed.
Members who live outside of the plan’s service area must use the plan’s participating providers as indicated in the plan materials and provider directory. The Member’s insurance ID card will display their network logo (such as PHCS, Multiplan, etc.) if they have options for care outside the plans’ service area. If the Member chooses to go to a non-participating provider when a participating provider is available, claims will be paid at the out-of-network benefit level if the Member has out-of-network benefits.
When Members receive services from a participating provider or obtain prescription drugs at network pharmacies, providers will file claims on behalf of the Member within 180 days of the service. Sanford Health Plan may deny claims by not filed within the 180-day window. If this occurs, charges that are denied may not be billed to the member.
If the Member does not provide their ID card at the time of service and the provider bills the wrong insurance company, the claim will be denied. The Member and provider will receive information explaining this denial, and the provider then takes responsibility for handling issues regarding the claim. If the 180-day filing period expires and the provider submits copies of documented attempts to obtain information from the Member and no response was given, then the Member may be responsible for payment of the claim.
Members may need to file a claim when receiving emergency services from Non-Participating Practitioners and/or Providers. Check with the Practitioner and/or Provider, as they may submit the claim to Sanford Health Plan on the members behalf. Members are responsible for making sure the claim is submitted to the Plan within one-hundred-eighty (180) days after the date that the cost was incurred. If the member or the Non-Participating Practitioner and/or Provider, does not file the claim within one-hundred-eighty (180) days after the date that the cost was incurred, the member will be responsible for payment of the claim.
If necessary, claims should be submitted to: Sanford Health Plan, PO Box 91110, Sioux Falls SD 57109-1110. A fillable claim form can be found here.
If the Member purchased their insurance coverage on the Marketplace (HealthCare.gov), they are receiving an advance premium tax credit (subsidy), and have previously paid at least one full month’s premium during the current benefit year, they will receive a 3 month (consecutive) grace period to pay missed premiums. Any claims received during the first month of the grace period will be paid, however, claims received during the 2nd and 3rd months will be held as “pending”. Claims that are pending will not be paid until delinquent premiums are paid in full.
Retroactive Denials are claims that were originally paid by the Plan, but are partially or full reversed at a later date after further review. In the case of a Retroactive Denial, the member will receive an explanation stating the previous charges paid by the Plan that are being reversed, and the reason for each reversal. After this occurs, the member is responsible for securing payment for any reversed charges.
There are a few ways that members can help themselves avoid these Retroactive Denials:
Premium refunds will be processed for the following reasons:
Members can call Sanford Health Plan customer service to request a refund if they believe they have overpaid their premium due.
Pre-approval (authorization or certification) is the approval of a requested service for medical care prior to receiving the service. Pre-approval is designed to aid early identification of a treatment plan to ensure medical management and available resources are provided throughout an episode of care. If medical care requires pre-approval, the member is ultimately responsible for obtaining it from Sanford Health Plan to receive in-network coverage per their benefit plan. Information supplied by a provider’s office will also satisfy this requirement. Failure to obtain pre-approval will result in a denial or payment at a reduced level. If the Member’s plan does not provide out-of-network coverage, benefits are not payable when the member fails to obtain pre-approval.
The plan determines approval for prior authorization based on appropriateness of care, service, and existence of coverage. Pre-approval is required for all inpatient admissions of members. See your plan documents for full details and a list of all services requiring pre-approval.
All requests for pre-approval (authorization or certification) are to be made by the Member at least three (3) business days prior to the requested service. Admission before the day of non-emergency surgery will not be authorized unless early admission is medically necessary and approved by the plan. Coverage for hospital expenses prior to the day of surgery will be denied unless authorized prior to being incurred.
Health Plan Responsibility:
Sanford Health Plan will review the Member’s request against standard medical necessity criteria. A determination for elective care will be made within fifteen (15) calendar days of receipt of the request. If the plan is unable to make a decision due to matters beyond its control, it may extend the decision time frame once, for up to fifteen (15) calendar days. In this case, Sanford Health Plan will notify the Member within the first fifteen (15) days after initial receipt of the request, and will provide an approximate date by which it expects to make a decision.
If the plan is unable to make a decision due to lack of information on elective requests, the plan may extend the decision period once for up to fifteen (15) calendar days. In this case, the Member will be contacted within the first fifteen (15) days after the initial receipt of request. The Member has 45 calendar days to provide the requested information. The actual extension period for Sanford Health Plan begins when the information is resubmitted (even if it is not correct), or at the end of the 45-day period that the Member has to resubmit information.
For urgent or emergent care needs, Sanford Health Plan will make a determination within 72 hours after receipt of request. If the plan is unable to make a decision due to lack of information, it may extend the decision time frame once for up to an additional 48 hours. In this case, the Member will be contacted within the first 24 hours after receipt of request. The Member then has 48 hours to submit correct information. The actual time extension for Sanford Health Plan begins either when the information is resubmitted (even if it is not correct), or when the 48-hour time period expires for the Member to resubmit information.
Medical necessity means the Member will receive health care services that are appropriate in terms of type, frequency, level, setting, and duration to the member’s diagnosis or condition, diagnostic testing and preventive services. The criteria used to determine whether a service, treatment, technology, prescription drug or supply is medically necessary, are:
Members are required to use medications on the Sanford Health Plan formulary, which is a list of FDA-approved brand name and generic medications chosen by health care providers on the Physician Quality Committee. Members are allowed to request and gain access to clinically appropriate drugs not covered under the formulary and may request an exception for:
A provider or Member should contact the Pharmacy Management Department to request coverage for the specific medication or drug. This can be done via a phone call, online fillable form submission (available to members when they log into their account), or letter of medical necessity requesting coverage for the specific medication or drug. The plan will use designated Pharmacy Management Department staff and/or appropriate practitioners to consider exception requests and promptly grant an exception to the formulary, including exceptions for anti-psychotic and other drugs to treat mental health conditions, for a Member when the provider prescribing the medication indicates to the plan that:
The prescription drug must be dispensed as written to provide maximum medical benefit to the Member
NOTE: Members must generally try formulary medications before an exception for the formulary will be made for non-formulary medication use.
After a member’s claim is processed, Sanford Health Plan sends the Member and the provider an EOB outlining the charges that were covered. The purpose of an EOB is to show how the plan paid for the Member’s services; it shows the amount billed and how that amount is applied to deductible, coinsurance or copayments, or if any of the charges were for non-covered services. Please reference the graphic below for specific information regarding what is feature on an EOB.
If a member is covered by another health plan, insurance, or other coverage arrangement, the plans and/or insurance companies will share or allocate the costs of the Member’s health care by a process called “Coordination of Benefits” so that the same care is not paid for twice. The Member has two obligations concerning Coordination of Benefits (“COB”):
The order of benefit determination rules governs the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accordance with its policy terms without regard to the possibility that another plan may cover some expense. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans does not exceed 100% of the total allowable expense. Refer to your plan documents for more detailed information.