Section 5: Quality Improvement Program

5.1 Quality Improvement Program

Sanford Health Plan and its participating practitioners and providers are fully supported by a sophisticated ambulatory and institutional quality management program. The organized method for monitoring, evaluating, and improving the quality, safety and appropriateness of health care services, including behavioral health care which encompasses mental health and substance use disorders, to members through related activities and studies is known as the Quality Improvement (QI) Program. The Plan monitors its use of resources in order to ensure appropriate distribution of assets throughout the entire system and provides accountability for the quality of health care delivery and service. This is accomplished through the commitment of the Board of Directors, the Physician Quality and the Health Plan Quality Improvement Committees.

Providers are encouraged to view the programs offered to members at the home screen of

  1. Case Management programs are available for our members who are high risk or have complicated health conditions. Our team of medical and behavioral health case managers provide telephonic outreach to assist with the coordination of health care services, provide education on health conditions and facilitate the coordination of resources to provide support to meet the member needs. The team works collaboratively with the member to set goals which are important to them and will 44 positively impact their health. By addressing these areas, members are better equipped to control and understand their condition, thereby lessening complications. Learn more in our “clinical toolbox.”
    • The programs offered are:
      • Very High Risk Case Management
      • Complex Case Management
      • Specialty Case Management (includes specific programs for: High Risk OB, NICU, End Stage Renal Disease, Transplant, Oncology and Behavioral Health) Medical and Behavioral Health Care Transitions
  2. Quality improvement activities 
  3. HEDIS® and CAHPS® Report The HEDIS® Provider Guide and Toolkit on the provider portal provides valuable information on HEDIS measure specifications, member experience survey questions related to providers and tips for improving performance.
  4. Clinical resources and tools which include but are not limited to: 

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

  • Quality Improvement Program (MM-056).

5.1.1 Complex Case Management Referral Guide

Complex case management (CCM) is a program that provides coordination of care and services to members who have experienced a critical medical event or diagnosis that requires the extensive use of resources and who may need help navigating the health care system to facilitate appropriate delivery of care and services.

The case managers will focus on members identified as having had: Catastrophic health event; Multiple chronic illnesses or chronic illness resulting in high utilization; High risk or complicated medical conditions

The goal of complex case management is to assist members to regain optimum health or improved functional capability. We ensure member care follows evidence based clinical standards so there are no gaps in care, and ensure members are receiving health care in a cost-effective manner. This program involves a comprehensive assessment of the member’s condition; determination of available benefits and resources; development and implementation of a case management plan with performance goals, monitoring and follow-up.

Sanford Health Plan’s Complex Case Management Program is available at no cost to qualifying Sanford Health Plan members and their families.

If you would like more information or need to refer a qualified Sanford Health Plan Member to the program, please contact the Care Management team at (888) 315-0884 or by email at

For Sanford EPIC users, you can also use in-basket messaging. If a Health Plan case manager is currently following a member, the case manager will be listed on the patient care team in One Chart. If you are unable to determine the assigned case manager, you can send an in-basket message to SHP CRM CT Case Management.

5.2 Medical Management Program

The Medical Management Program (also referred to as Utilization Management or UM) is defined as an organized method for monitoring and evaluating certain services and treatment using evidence-based guidelines. This process reviews the following items to determine if the treatment, as prescribed, is appropriate:

  1. Medical necessity of the treatment 
  2. Setting for the treatment
  3. Types and intensity of resources to be used in the treatment
  4. Time frame and duration of the treatment

Our Utilization Management Team is available between the hours of 8 a.m. and 5 p.m., CST, Monday through Friday (excluding holidays). After hours, members and providers may leave a message on the confidential voice mail and a representative will return your call the following business day, no later than 24 hours after the initial inquiry call.

Member questions per line of business:
NDPERS: (888) 315-0885
ND Medicaid Expansion: (855) 276-7215
All other: (800) 805-7938

5.2.1 Utilization Review Process

The purpose of Utilization Review is to establish requirements and standards of operation for the certification of medical utilization. The criteria for medical services used by the Utilization Management Department shall be made available, upon request, to Participating Physicians. Clinical review criteria may be developed based on Milliman Care Guidelines (MCG), eviti, literature review, specialty society standards of care, Medicare guidelines, and health plan benefit interpretation.

If medical necessity and/or criteria are not met, the request is reviewed by a Medical Director/ Officer. UM staff cannot make denial decisions in these cases, but can make authorization decisions based on MCG guidelines, procedures and benefit coverage guidelines. UM staff base their decisions on accepted review criteria, medical record review, and/or consultations with appropriate physicians.

5.2.2 New Medical Service or Product Consideration

Provider can request review where there is a new medical service or product Sanford Health Plan to consider for benefit coverage. Please contact provider relations at (800) 601-5086 or to request this review.

5.2.3 Prior Authorizations

Prior authorization (certification or precertification) is the urgent or non-urgent authorization of a requested service prior to receiving the service. The approval for prior authorization is based on appropriateness of care and service and existence of coverage. Points to remember:

  1. Providers are responsible for obtaining prior authorization in order to receive in-network coverage. However, information provided by your office will also satisfy this requirement.
  2. All requests for certification are to be made by the member or their practitioner’s office at least three working days prior to the scheduled admission or requested service. If health care services need to be provided within less than three working days, contact the Utilization Management Department to request an expedited review.
  3. All referrals to non-participating providers (at the recommendation of a participating provider) require prior authorization.
  4. A list of services that require prior authorization can be found online at

For questions on authorizations, please visit or contact at (855) 305-5062 or (800) 805-7938.

How to Authorize:
Prior authorizations for health care services can be obtained by contacting the Utilization Management Department online, by phone or fax: NOTE: Oncology treatment and services must be entered and authorized through eviti|Connect online at High-end imaging services for select members and health plans must be entered and authorized through eviCore at

To request a prior authorization, log into the mySanfordHealthPlan provider portal at Open the member record and choose “Create Referral”. The tutorial explaining how to request a prior authorization is located within the provider portal.

The date of receipt for non-urgent requests received outside of normal business hours will be the next business day. The date of receipt for urgent requests will be the actual date of receipt, whether or not it is during normal business hours.

Additional Medical Management Program Information
You may also find the following information in mySanfordHealthPlan provider portal in the “Quick Links” section under “Policies & Medical Guidelines” at

  1. The complete Medical Management Program Description, including further operational details, prior authorization and denial and appeal procedures are available.
  2. UM criteria is available to practitioners and providers by phone or mail. A physician reviewer is made available by phone to any practitioner to discuss determinations based on medical appropriateness.

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

  • Utilization Management Program policy (MM-049).

5.2.4 Sanford Health Plan Referral Center

The Referral Center assists providers in finding the right specialist or medical resources for your Sanford Health Plan patient. The center will have access to all Sanford Health Plan network specialists, contact information, services and procedures provided and their location(s)/ outreaches within our service area. Our staff will give personal attention to each inquiry by gathering details about the patient and will give you available options.

Who can use?
Providers and nursing staff can call the referral center and identify the type of specialty their patient needs.

How do you contact the Referral Center?
The Referral Center will be available for consultation by phone or email. Call (844) 836-1616 or (605) 333-1616, or email

Staff will be available Monday – Friday, 7:30am-6:30pm CST.

5.2.5 Coordinated Services Program (CSP)

Sanford Health Plan administers a CSP as allowed under 42 CFR § 431.54 specifically for the ND Medicaid Expansion population. The CSP is in place to restrict a Member (who meets specific criteria) in to a pharmacy and/or a primary care physician. RN and Behavioral Health case managers work with the member in coordinating healthcare services to match their medical needs, improve quality of care by building a patient-doctor relationship, and to promote proper use of health care services and medications.

Members in this program will have one CSP doctor, psychiatrist and one CSP pharmacy. Sanford Health Plan selects the CSP doctor, psychiatrist and pharmacy based on past utilization. Members do have the right to appeal their participation in the program and have 30 days from the time they are notified to request a change in their CSP doctor or pharmacy.

Providers chosen as a CSP doctor will be notified that they are the primary contact for medical needs, with the exception of emergencies. CSP members will be required to get all prescriptions from the assigned CSP pharmacy. The plan will monitor and review members on an annual basis for continuation in the CSP program. You will be notified when a member is no longer required to be in the CSP program. CSP doctors will agree to:

  • Manage all medical care for the member
  • Educate the member on the appropriate use of services
  • Provide referrals to specialty physicians
  • Be available telephonically or ensure a provider of comparable specialty is available 24 hours a day, 7 days a week for urgent or emergent medical situations
  • Manage acute and/or chronic pain through a variety of services or treatment options
  • Approve or deny medications prescribed by other providers when contacted by the specific CSP pharmacy 
  • Work with pharmacists and other specialty physicians to share pertinent information regarding the member.

5.2.6 Pharmacy Management and Formulary Program Information

One of Sanford Health Plan’s missions is to improve the health status of members by developing a model of quality patient care. We maintain a physician driven Pharmacy and Therapeutics Committee in order to promote unbiased, clinically sound drug therapy for Plan participants covered by the formularies managed by the Plan. Criteria utilized to determine drug status within the Formulary includes clinical efficacy and safety, financial impact of medications to the Member and Employer Group, consistency in formulary decisions, and drug position among therapeutic alternatives. Medications on this list are approved by the Federal Food and Drug Administration (FDA) for use in the United States. We contract with OptumRx as our Pharmacy Benefits Manager to promote optimal therapeutic use of pharmaceuticals. OptumRx currently supports the Plan’s Formulary for self-administered medications payable under the pharmacy benefit. Participating pharmacies can be found through our online, searchable pharmacy directory.

To be covered by the Plan, drugs must be:

  1. Prescribed or approved by a physician, advanced practice provider or dentist;
  2. Listed in the Plan Formulary, unless pre- approval (authorization) is given by the Plan;
  3. Provided by a Participating Pharmacy except in the event of a medical emergency. If the prescription is obtained at a Non-Participating Pharmacy, the member is responsible for the prescription drug cost in full;
  4. Approved by the Federal Food and Drug Administration (FDA) for use in the United States.

5.2.7 Sanford Health Plan Formulary

Sanford Health Plan has a list (formulary) of prescribed medications chosen by health care providers on Sanford Health Plan’s Pharmacy and Therapeutics Committee. By following the formulary and using generic medications when available, members can save money and help control out of pocket costs. The Plan updates the Formulary on an annual basis and as needed when new drugs enter the market or when a drug is removed from the market.

If changes are made to the formulary, members who are directly impacted receive a letter from Sanford Health Plan with notification of the formulary change.


  1. Sanford Health Plan website: Formularies, medications requiring prior authorization or step therapy, Synagis Prior Authorization Form, options on obtaining prior authorization etc. can be found online and within the secure provider portal. 
  2. OptumRx website:

If you feel that Sanford Health Plan should consider coverage of a medication based on medical necessity for medications not on the Formulary, please complete the online Prescription Drug Prior Authorization Request online at our provider portal.

The Pharmacy Management Department can be reached from 8 a.m. to 5 p.m., Central Time, Monday through Friday at one of the following numbers: