Section 4: Provider Relations

4.1 Provider Relations Department

Our Provider Relations staff members are here to help you with your questions regarding contracting/ credentialing, or questions related to claims payment.

Phone: (800) 601-5086 Option 2 for Provider and Option 4 for Provider Relations or email to
Email: providerrelations@sanfordhealth.org.

4.2 Contracting Department

In order to provide a full range of health care services to our members, our provider relations department annually evaluates our network against our access and availability standards and state requirements. We contract with physicians, hospitals and other health care providers for appropriate geographic access and to ensure sufficient capacity throughout the entire service area. In addition, we annually assess the cultural, ethnic, racial and linguistic needs of our members to ensure the availability of bilingual practitioners

To become a participating provider, a contract and fee schedule must be signed. A completed credentialing application and W-9 form is also required. When the facility or provider has been approved through the credentialing process, providers are granted participating provider status, allowing them to appear in our online provider directory.

The contracting department can be contacted by phone: (855) 263-3544; or email: sanfordhealthplan providercontracting@sanfordhealth.org.

Sanford Health Plan partners with Careington International Corporation in offering a discount card program to our individual and small employer groups (both on and off the Marketplace). The Careington discount program is not insurance and is separate from an agreement with Sanford Health Plan. For dental, vision and audiology providers wanting to get more information on joining Careington International Corporation’s discount card program, you can contact a Careington recruiter at (800) 441-0380 ext. 7143.

4.3 Credentialing & Re-credentialing

Credentialing is the process of verifying that an applicant meets the established standards and qualifications for consideration in the Sanford Health Plan network. Initial credentialing is performed when an application is received. In general, the credentialing and re-credentialing is performed at least every 36 months. Process applies to:

  • Practitioners who have an independent relationship with the organization. 
  • Practitioners who see members outside the inpatient hospital setting or outside free- standing ambulatory facilities.
  • Practitioners who are hospital based, but who see the organization’s members as a result of their independent relationship with the organization. 
  • Non physician practitioners who have an independent relationship with the organization who can provide care under the organization’s medical benefits.

During the initial credentialing period, providers should submit claims to Sanford Health Plan. However, all claims for the provider will be pended until the credentialing process is complete. Once the provider is approved by the credentialing committee, the pended claims will release for processing.

Claims must be submitted within 180 days from the date of service or as defined by your contract. The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/Provider

  • Practitioner Credentialing Policy (PR-006)
  • Criteria for Credentialing and Re-credentialing Participating Practitioners (Pr-010) 
  • Organizational Provider Credentialing (PR-020)

4.3.1 Locum Tenans providers

Locum Tenans arrangement is when a physician is retained to assist the regular physician’s practice for reason such as illnesses, pregnancy, vacation, staffing shortages or continuing medical education. Locum Tenans generally have no practice of their own and travel from area to area as needed. Locum Tenans who are providing coverage for a physician for 60 consecutive days or less do not need to be fully credentialed. However, if the Locum Tenans cover for periods longer than 60 consecutive days, Sanford Health Plan will require the provider to complete the credentialing process and they will no longer be allowed to bill with the absent provider’s NPI. 

  • The locum tenans provider must submit claims using the provider NPI and tax ID of the physician for whom the locum tenans provider is substituting or temporarily assisting. 
  • Bill with modifier Q6 in box 24d of the CMS-1500 form for each line item service on the claim
  • The code(s) being billed must qualify for the Q6 modifier for payment

4.3.2 Supervising Physician

A Supervising Physician is a licensed physician in good standing who, pursuant to US State regulations, engages in the direct supervision of a practitioner with limited licensure. Claims using the supervising physician’s name and provider number can be used where the practitioner is still working towards licensure, or has limited licensure.

Supervising physicians may not bill separately for services already billed under these circumstances, unless there are personal and identifiable services provided by the teaching physician to the patient they performed in management of the patient. Sanford Health Plan does not require PA’s or APRN’s to bill with the name of their supervising physician on the claim form.

4.4 Credentialed Providers

The following types of practitioners are eligible for Participating Provider status provided that they possess and provide satisfactory evidence as required through the Sanford Health Plan credentialing process. The types of practitioners requiring credentialing by Sanford Health Plan include, but are not limited to:

  • Doctors of Allopathy 
  • Doctors of Osteopathy
  • Physician Assistants *
  • Nurse Practitioners * 
  • Certified Nurse Midwife * 
  • Certified Diabetic Educator
  • Licensed/Registered Dietitian
  • Podiatrists
  • Chiropractors
  • Optometrists
  • Audiologists (master’s level or higher)
  • Speech Pathologists
  • Physical Therapists
  • Occupational Therapists
  • Dentists
  • Oral/Maxillofacial Surgeons
  • Nurse Anesthetists (nonhospital based or independent relationship)
  • Other practitioners with Master’s level training or higher who have an independent relationship with Sanford Health Plan
  • Locum Tenens providers who have practiced in the same location or on a contracted period of more than 60 consecutive days
  • Behavioral Health Practitioners
    • Psychiatrists
    • Psychologists, social workers, counselors, marriage and family therapists (licensed at master’s level or higher)
    • Addiction medicine specialists
    • Clinical nurse specialists or psychiatric nurse practitioners (master level or higher who are nationally or state certified or licensed) 
      • Resident must be at a minimum midway through he/she second year (PGY2) of residency training to be eligible for credentialing.
      • A letter from the Residency Program Director must be submitted allowing the resident to moonlight outside of the residency training.
      • Credentialing cycle will end 60 days after estimated residency completion date.
  • Anesthesiologist with pain management practices
  • Clinical nurse specialists (master level or higher who are nationally or state certified or licensed.)*
  • Advanced Practice Registered Nurses (master level or higher who are nationally or state certified or licensed.)
  • Telemedicine practitioners who have an independent relationship with the organization and who provide treatment services under the organizations medical benefit. Practitioners providing medical care to patients located in another state are subject to the licensing and disciplinary laws of that state and must possess an active license in that state for their professions.

Nurse Midwives, Nurse Practitioners, Physician Assistants and Clinical Nurse Specialist must have an agreement with a licensed physician or physician group unless the state law allows the practitioner to practice independently. This is in reference to H.R. 3590 – Patient Protection and Affordable Care Act C. 2706, non-discrimination in health care and 42 U.S.C. 300gg-5. Non-discrimination in health care. State laws requiring collaborative agreements will be required by Sanford Health Plan.

4.5 Practitioners Who Do Not need to be Credentialed/Re-credentialed

4.5.1 Inpatient Setting

Practitioners who practice exclusively within the inpatient setting and who provide care for members only as a result of an inpatient stay do not need to be credentialed. Examples include:

  • pathologists 
  • radiologists 
  • anesthesiologists 
  • neonatologists 
  • emergency room physicians
  • hospitalists 
  • board certified consultants
  • locum tenens physicians who have not practiced at the same facility for 60 or more consecutive calendar days and do not have an independent relationship with Sanford Health Plan
  • nurse anesthetists (hospital based)

4.5.2 Freestanding Facilities

Practitioners who practice exclusively within freestanding facilities and who provide care for members only as a result of members being directed to the facility do not need to be credentialed. Examples include: 

  • Mammography centers
  • Urgent care centers
  • Surgical-centers 
  • Ambulatory behavioral health care facilities (i.e. psychiatric and addiction disorder clinics)

4.5.3 Practitioners who are not accepted by Sanford Health Plan

The following listing of practitioner types will not be credentialed:

  • Registered Nurses
  • Licensed Practical Nurses 
  • Certified professional midwives in addition to lay or direct entry midwives
  • Practitioners not providing all required documentation in addition to a completed and attested to credentialing application
  • Practitioners who have not yet received their required license by their state Practitioners who are currently on a leave of absence. In the event that the practitioners credentialing cycle expired during the leave of absence, the practitioner must reapply within 30 days of returning to practice.
  • Providers excluded from participation in federal health care programs under either section 1128 or section 1128A of the Balanced Budget Act of 1997 or any provider excluded by Medicare, Children’s Health Insurance Program, or Medicaid

4.6 Ongoing Monitoring Policy

Sanford Health Plan identifies and takes appropriate action when practitioner quality and safety issues are identified. Sanford Health Plan monitors ongoing practitioner sanctions or complaints between re- credentialing cycles. Per contract, all practitioners need to report a Serious Reportable Event or a Never Event. Sanford Health Plan and its delegates, will monitor on an ongoing basis: 

  1. Medicare and Medicaid sanctions
  2. State sanctions or limitations on licensure 
  3. Complaints against practitioners
  4. Adverse events

Sanford Health Plan will delegate this responsibility to its contracted delegates as long as the processes in those policies meet the intent of NCQA and Sanford Health Plan standards. A practitioner in good standing means that no sanctions can be identified through the Office of Inspector General (OIG), state sanctions or complaints to that specific practitioner. When sanctions are identified between re-credentialing cycles or the number of Quality Risk Issues exceeds the Sanford Health Plan threshold of five within two years, then the practitioner will be presented to the Sanford Health Plan Credentialing Committee through formal re-credentialing so the sanctions and/or complaints can be peer reviewed.

Sanford Health Plan Credentialing Committee reviews all sanctions, limitations of licensure, adverse events and complaints. The Committee determines the appropriate interventions when instances of poor quality are identified. Recommendations to approve the practitioner with additional education or required supervision, or may require the practitioner a one-year re-credentialing cycle. The Committee may also decide other courses of improvement based on the evidence provided.

In the event that the Committee determines that the practitioner possesses serious quality issues and is no longer fit to participate in the network, the practitioner will be sent formal appeal rights. If the final result is termination of that practitioner from the Sanford Health Plan provider network, the appropriate agencies will be contacted.

All decisions made by the Sanford Health Plan Credentialing Committee are reviewed and approved by the Sanford Health Plan Board of Directors. The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/Provider.

  • Monitoring Policy (PR-024)
  • Quality of Care (MM-GEN-030)

4.7 Provider Rights & Responsibilities

4.7.1 Right to Review & Correct Credentialing Information

Practitioners have the right to review information submitted in support of their credentialing applications, however, Sanford Health Plan respects the right of the Peer Review aspects that are integral in the credentialing process. Therefore, practitioners will not be allowed to review references or recommendations or any other information that is peer review protected. All other information obtained from an outside source is allowed for review.

If during the review process, a practitioner discovers an error in the credentialing file, the practitioner has the right to correct erroneous information. The practitioner will be allowed 10 days to provide corrected information. Sanford Health Plan will accept corrected information over the phone, in person, or via voice mail. Corrected information must be submitted to the appropriate Credentialing Specialist who is processing the file.

Finally, each contracted practitioner retains the right to inquire about their credentialing application status. Contact a representative of the Provider Relations Team.

If there are new practitioners added to existing participating facility/groups, Sanford Health Plan requires the new practitioner complete a Provider Credentialing Application. Our Credentialing Application can be found HERE. Contact the Provider Relations Team at (800) 601-5086 if you have questions.

The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/Provider.

  • Practitioner Credentialing Policy (PR-006).

4.7.2 Refusing to Treat a Sanford Health Plan Member

Providers have the right to refuse to provide services to a Sanford Health Plan member. Providers are not to differentiate or discriminate in the treatment of Members or in the quality or timeliness of services delivered to Members on the basis of race, color, ethnicity, sex, age, religion, marital status, sexual orientation, sexual identity, place of residence, national origin, health status, genetic information, lawful occupation, source of payment, credit history, frequency of utilization of services or any other basis prohibited by law. While this is a very rare event, it is required that the provider office contact the Care Management Team at (888) 315-0884 as soon as possible so we can assist the member in transitioning to a new provider.

4.7.3 Member Eligibility Verification

Each provider is responsible for ensuring that a member is eligible for coverage when services are rendered. Member eligibility can be determined by logging on to your secure online provider account. If you don’t have an account, see the Online Resources section of this manual. In addition, our Customer Service Team can also assist you with member eligibility status questions. If the provider provides services to a patient not eligible for coverage and remits a claim to Sanford Health Plan, the claim will be denied.

Please note: Sanford Health Plan may be notified by NDDHS that a member has lost eligibility retroactively. When this happens, federal regulations require Sanford Health Plan, as the MCO, to recoup payments made on an individual determined by the state of ND to be ineligible for coverage.

4.7.4 Medical Record Standards

Sanford Health Plan ensures that each provider furnishing services to members maintains a medical record in accordance with professional, State, NCQA and CMS standards as well as standards for the availability of medical records appropriate to the practice site. Contracted practitioners/providers are required to maintain a medical record on each individual member for a minimum of ten years from the actual visit date of service or resident care.

Records of minors shall be retained until the minor reaches the age of majority plus an additional two years, but no less than ten years from the actual visit date of service or resident care. Medical records are reviewed by our Care Management Team at a sample of clinics at least once per calendar year. Medical record review is conducted in conjunction with the HEDIS data collection process.

Medical records may be requested by Sanford Health Plan in connection with utilization or quality improvement activities, or may be requested as verification to support a claim. Well documented medical records facilitate communication, coordination and continuity of care; and they promote the efficiency and effectiveness of treatment.

A medical record is defined as patient identifiable information within the patient’s medical file as documented by the attending physician or other medical professional and which is customarily held by the attending physician or hospital. These medical records should reflect all services provided by the practitioner including, but not limited to, all ancillary services and diagnostic tests ordered and all diagnostic and therapeutic services for which the member was referred by a practitioner (i.e., home health nursing reports, specialty physician reports, hospital discharge reports, physical therapy reports, etc.).

Medical records are to be maintained in a manner that is accurate, up-to-date, detailed and organized and permits effective and confidential patient care and quality review. Documentation of items from the ”Standards and Performance Goals for the Medical Record” demonstrates that medical records are in conformity with good professional medical practice and appropriate health management. The organization and filing of information in the medical record is at the discretion of the participating provider. The Plan’s documentation standards for medical record review include 17 components. However, there are only 9 critical elements required in the medical record to demonstrate good professional medical practice and appropriate health management. Periodic medical record documentation reviews will be completed in conjunction with HEDIS medical record reviews.

The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/Provider.

  • Medical Record (MM-024)

4.7.5 Practitioner Office Site Quality

Sanford Health Plan has established standards for office-site criteria and medical record-keeping practices to ensure the quality, safety and accessibility of office sites where care is delivered to Sanford Health Plan members. The office site standards are as follows:

  1. Physical Accessibility
  2. Physical Appearance
  3. Adequacy of Waiting and Examining Room Space
  4. Adequacy of medical treatment record keeping paper based medical records 
  5. Electronic Medical Records

Sanford Health Plan monitors member complaints about office site quality. If Sanford Health Plan has received three or more complaints within a six month period, a Provider Relations Specialist will conduct an onsite visit within 60 days of the third complaint. The onsite visit will consist of a assessment of the physical appearance of the clinic, the physical accessibility and adequacy of waiting and patient exam rooms, adequacy of medical record keeping, as well as identification of any other deficiencies. If deficiencies are detected, the practitioner’s office will be asked to implement an improvement plan. Sanford Health Plan will conduct additional on site visits every six months until the deficiency has been corrected.

Sanford Health Plan will take into consideration the severity of the complaint and if we feel it is necessary, we reserve the right to conduct an onsite visit at any time regardless if an office has incurred a complaint.

The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/Provider

  • Practitioner Office Site Quality Policy (PR-009)

4.7.6 Cultural and Linguistic Competency

Sanford Health Plan is committed to embracing the rich diversity of people we serve and believes in providing high-quality services to culturally, linguistically and ethnically diverse population, as well as those with physical, mental, visual and hearing impairment. To be Cultural and Linguistic Competent, means that Providers meet the unique, diverse needs of members, values & diversity within the organization, and identifies members with distinct needs in establishing access to care and support. Providers shall recognize and ensure members receive equitable and effective treatment in an understandable and respectful manner, recognizing individual spoken language(s), gender and orientation, and the role culture plays in a member’s health and well-being in a culturally sensitive manner.

Cultural competency is a set of congruent behaviors, attitudes and policies that enable effective work and communication cross-cultural situation. The awareness of culture is the ability to recognize the cultural factors, norms, values, communications patterns/types, socio-economic status and world views that shape personal and professional behaviors. Culturally and Linguistic Appropriate services (CLAS) are health care services respectful of, and responsive to, cultural and linguistic needs.

The delivery of culturally competent health care and services requires health care Providers and their staff to integrate and transform skills, service approach, techniques and marketing materials to match population culture and increase the quality and appropriateness of health care services and outcomes.

The objectives of Cultural Competency are to:

  • Identify and accommodate those with physical and mental disabilities
  • Identify Members who have potential cultural or linguistic barriers and provide alternative communication methods where needed 
  • Utilize culturally sensitive and appropriate educational materials based on the Member’s race, ethnicity and primary language spoken (including American Sign Language).
  • Make resources available to meet the unique language barriers and communication barriers existing in the population
  • Provide education to associates/staff on the value of cultural and linguistic awareness and differences in the organization and the populations served 
  • Decrease health care disparities in the minority populations served and understand how socio-economics status impacts care Sanford Health Plan expects Providers to: 
  • Have written materials available for Members in large print format and certain non-English languages, prevalent in SHP’s service areas
  • Provide ADA accessible offices, exam tables and equipment
  • Telephone system adaptations for Members needing the TTY/TDD lines for hearing impaired services and other auxiliary impairment services
  • Access to skilled interpreters to translate in non-English languages including American Sign Language or contact Sanford Health Plan for assistance.
  • Obtain Cultural Competency Training including the review of materials on the Sanford Health Plan Provider Portal and/or Newsletters.

For additional free provider and staff education on Cultural and Linguistic Competency and education and training visit HHS.gov national website HERE.

4.8 Primary Care Responsiblities

As a Primary Care Physician contracting with the Plan, the Physician shall provide the following services to Members in accordance with applicable Plan Health Maintenance Contracts:

  1. The Physician may have the primary responsibility for arranging and coordinating the overall health care of members who select the Physician as their Primary Care Physician. This includes appropriate referral to specialist Physicians and Providers under contract with the Plan, arranging for the care and treatment of such Member by hospitals, skilled nursing facilities and other health care providers who are Participating Providers, and managing and coordinating the performance of administrative functions relating to the delivery of health services to such Members in accordance with this Agreement. 
  2. Routine office visits (including after-hours office visits which can be arranged with other Plan Physicians and with Plan approval) and related services of the Physician and other health care providers received in the Physician’s office, 40 including evaluation, diagnosis and treatment of illness and injury.
  3. Visits and examinations, including consultation time and time for personal attendance with the Member, during a confinement in a hospital, skilled nursing facility or extended care facility.
  4. Adult immunizations in accordance with accepted medical practice or Plan policies and protocols.
  5. Administration of injections, including injectables for which a separate charge is not routinely made.
  6. Well-child care from birth for pediatric Members assigned to Physician.
  7. Periodic health appraisal examinations
  8. Eye and ear examinations for Members to determine the need for vision or hearing correction.
  9. Diagnosis of alcoholism or drug abuse and appropriate referral to medical or non-medical ancillary services, but not the cost of such referral services.
  10. Routine office diagnostic testing, including chest x-rays, electrocardiograms, serum chemistries, throat cultures and urine cultures and urinalysis, including interpretation; and interpretation of testing performed outside the Primary Care Physician’s office. 
  11. Miscellaneous supplies related to treatment in Primary Care Physician’s office, including gauze, tape, Band-Aids, and other routine medical supplies.
  12. Physician visits to the Member’s home or office when the nature of the illness dictates, as determined by the Primary Physician. 
  13. Patient health education services and referral as appropriate, including informational and personal health patterns, appropriate use of health care services, family planning, adoption, and other educational and referral services, but not the cost of such referral services.
  14. Telephone consultations with other Physicians and Members.
  15. Other primary care services defined by normal practice patterns for Primary Care Physicians in the Plan’s service areas required by the Plan.
  16. Such minor surgical procedures as the Physician ordinarily provides during the course of his/her practice to his/her patient population on a fee for service or indemnity basis. The list of provided services does not include those services ordinarily provided as a specialty service in consultation.
  17. Primary care physicians (PCP) have agreed to be available to members twenty-four (24) hours a day, seven days a week for urgent care. Members should call during normal office hours for routine situations, and only call after hours in emergency or urgent situations. Members who leave messages should receive a return call within thirty (30) minutes, or as soon as possible.

4.9 Access Standards

4.9.1 Primary Care Physician

Through the contract and credentialing process, Primary Care Physicians (PCP) have agreed that urgent care services will be available to members 24 hours a day, seven days a week. Members should call during normal office hours for routine situations, and only call after hours for emergency or urgent care. Members leaving a message with the answering service of the PCP or the doctor on call should receive a call back within 30 minutes or as soon as possible. Providers are prohibited from offering reduced hours to State or Government Program populations. The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealth.org/ Provider.

  • Provider Access and Availability Standards Policy (MM-Q-050)

4.9.2 Emergency Services

In an emergency, members are encouraged to proceed to the nearest participating emergency facility. If the emergency condition is such that a member cannot go safely to the nearest participating emergency facility, then members should seek care at the nearest emergency facility. The member or a designated relative or friend must notify the Plan and the member’s Primary Care Physician (if applicable) as soon as reasonably possible and no later than 48 hours after physically or mentally able to do so.

Sanford Health Plan covers emergency services necessary to screen and stabilize members without precertification in cases where a prudent layperson, acting reasonably, believed that an emergency medical condition existed. The coverage shall be at the same benefit level as if the service or treatment had been rendered by a Participating Provider.

The Health Plan also covers emergency services if an authorized representative, acting for the Plan, has authorized the provision of emergency services.

4.9.3 Urgent Care Situation

An urgent care situation is a degree of illness or injury which is less severe than an emergency condition, but requires prompt medical attention within 24 hours, such as stitches for a cut finger. If an urgent care situation occurs, members should contact their Primary Care Physician (if applicable) or the nearest participating provider, urgent care or after hours clinic.

If a member is admitted to the hospital, the member or a designated relative or friend must notify the Plan and the member’s Primary Care Physician (if applicable) as soon as reasonably possible and no later than 48 hours after physically and mentally able to do so.

If a member is admitted to a non-participating facility, the Plan will contact the admitting physician to determine medical necessity and a plan for treatment. With respect to care obtained from a non-participating provider within the Plan’s service area, the Plan shall cover emergency services necessary to screen and stabilize a covered person. This may not require prior authorization if a prudent layperson would have reasonably believed that use of a Participating Provider would result in a delay that would worsen the emergency, or if a provision of federal, state, or local law requires the use of a specific provider. The coverage shall be at the same benefit level as if the service or treatment had been rendered by a Participating Provider.

4.9.4 Ambulance Service

The Plan covers local ambulance services for the following: 

  • Emergency transfer to a hospital or between hospitals.
  • Planned transfer to a hospital or between hospitals.
  • Transfer from a hospital to a nursing facility.

Planned transfer to a hospital or between hospitals and transfers from a hospital to a skilled nursing facility will only be covered when determined by the Plan to be medically necessary either before or after the ambulance is used. Prior authorization is required for non-emergent ambulance services. The Plan does not cover charges for an ambulance when used as transportation to a doctor’s office for an appointment.

4.9.5 Out of Area Services

If an emergency occurs when traveling outside of the Plan’s service area, members should go to the nearest emergency facility to receive care. The member or a designated relative or friend must notify the Plan and the member’s Primary Care Physician (if one has been selected) as soon as reasonably possible and no later than 48 hours after physically and mentally able to do so.

In-network coverage will be provided for emergency conditions outside of the service area if the member is traveling outside the service area but not if the member has traveled outside the service area for the purpose of receiving such treatment.

If an urgent care situation occurs when traveling outside of the Plan’s service area, members should contact their primary care physician immediately, if one has been selected, and follow his or her instructions. If a primary care physician has not been selected, the member should contact the Plan and follow the Plan’s instructions.

In-network coverage will be provided for urgent care situations outside the service area but not if the member has traveled outside the service area for the purpose of receiving such treatment.

Out-of-network coverage will be provided for non- emergency medical care or non-urgent care situations when traveling outside the Plan’s service area.

4.9.6 Treatment of Family Members

Sanford Health Plan takes the position that it is not appropriate for a provider to provide health care services to immediate family members, including any person normally residing in the Member’s home. There are however exceptions: This exclusion does not apply in those areas in which the 42 immediate family member is the only Provider in the area. If the immediate family member is the only Participating Provider in the area, the member has the following options:

  • The Member may be treated by that Provider if acting within the scope of their practice.
  • The Member may also go to a Non-Participating Provider and receive In-Network coverage with an approved prior authorization.

If the immediate family member is not the only Participating Provider in the area, the Member must go to another Participating Provider in order to receive coverage at the in-Network level. Claims denied for treatment of family members will deny with the following code: EX40-Charges for treating self/family members are ineligible

4.9.7 Provider Terminations

As stated in our contract(s), all provider(practitioner, organization, and hospital) voluntary terminations must be made in writing to Sanford Health Plan 60 days prior to the effective termination date. For Minnesota practitioners or facilities, you must give Sanford Health Plan 120 day notice.

Involuntary terminations will be sent to the provider via letter from Sanford Health Plan 60 days prior to the effective termination date.

The following policy(s) are referenced in this section and are available for review in the provider portal:

  • Provider Access and Availability Standards Policy (MM-50)

4.9.8 Notification of Provider Network Changes

Sanford Health Plan performs bi-annual surveys using a random sampling of our provider network to verify the accuracy of information displayed on our provider directory.

If there are changes to the provider network, Sanford Health Plan will notify its members in a timely manner. Members have access to the online provider directory, 24 hours a day, seven days per week via their secure member accounts or at sanfordhealthplan.com. All providers who have agreed to participate with the Plan shall be included in the directory for the duration of their contract.

When a provider terminates his or her contract, a letter is sent to each member who has incurred a service from that provider within the last 12 months. The letter will inform the member that the provider is leaving our network as of a specified date.

If you have changes affecting your clinic, notify us as soon as possible. The following are the types of changes that must be reported:

  • New address (billing and/or office)
  • New telephone number
  • Additional office location
  • Provider leaves practice 
  • New ownership of practice
  • New Tax Identification Number
  • Accepting new patients 
  • Change in liability coverage 
  • Practice limitations (change in licensure, loss of DEA certificate, etc.)
  • New providers added to a practice
  • Change in Medicare or Medicaid Status

All written notices should be clear and legible. This will ensure accuracy and allow for changes to be completed in a timely manner. A Provider Information Update/Change Form is also available online to submit changes. You can also send us your changes on your letterhead and fax to (605) 328-7224 or you may mail the information to the following address:

Attn: Provider Relations
Sanford Health Plan
PO Box 91110
Sioux Falls, SD 57109-1110