What is a prior authorization

Before you receive certain medical services or treatments, you may be required to get approval from your health plan. This process is known as prior authorization. Learn about when prior authorization is needed and the necessary steps for obtaining approval.
Why is prior authorization sometimes required?
Prior authorization allows health insurance companies to review health care services, procedures and medications to make sure they are medically necessary and safe. Your health plan determines approval for prior authorization based on appropriateness of care, service and coverage.
Prior authorization is never needed for emergency care.
Who needs to obtain prior authorization?
You or your doctor’s office must obtain prior authorization. Your request must be submitted at least three business days before approval is needed to receive in-network coverage. If you need health care services within less than three days, request an expedited review through the utilization management department.
How do I request prior authorization?
You can request prior authorization by contacting our utilization management department. After logging into your member account at member.sanfordhealthplan.com, select “Ask a question” under “Contact us” and then select the link for utilization management.
You can also call us during our business hours, Monday through Friday.
- NDPERS members: Call (888) 315-0885 from 8 a.m. to 5:30 p.m. CT
- Commercial, self-funded or Sanford Group Health members: Call (800) 805-7938 from 8 a.m. to 5 p.m. CT After hours, you may leave a confidential voicemail and we will return your call during the following business day.
Which services require prior authorization?
Prior authorization is needed for specific procedures, medications and some types of durable medical equipment, among other services. All referrals to non-participating providers or facilities also require prior authorization.
View a general list of procedures and services that must obtain approval. This list is subject to change based on Sanford Health Plan medical management policy updates, and the specifics for some plans may vary slightly from the listed or noted exceptions.
Please Note: Admission before the day of non-emergency surgery will not be covered unless the early admission is medically necessary and specifically approved by Sanford Health Plan.
Coverage for hospital expenses prior to the day of surgery at an out-of-network facility will be denied unless authorized before being incurred.