Sanford Health Plan offers two convenient options to verify eligibility and benefits: online or by phone.
Contact our Customer Service Department:
Phone: (800) 752-5863 or (605) 328-6800
from 8 a.m. to 5 p.m. CST, Monday through Friday.
Online: sanfordhealth.org/Provider.
Each provider’s office is responsible for ensuring that a member is eligible for coverage when services are rendered or prior to time of service. If a provider’s office fails to check eligibility for a member who is not eligible for coverage and submits a claim to Sanford Health Plan, the claim will be denied.
Sanford Health Plan processes eligibility files received from North Dakota Department of Human Services (NDDHS) for benefits and claims adjudication. Please note: Sanford Health Plan may be notified by NDDHS that a member has lost eligibility retroactively. When there is a change in eligibility, Sanford Health Plan will process any overpayments by taking deductions on future claims. Claim adjustments will appear on the next EOP for any effected claims.
Providers are able to verify member’s eligibility with North Dakota traditional Medicaid by accessing the ND Health Enterprise MMIS portal, or by contacting the ND Automated Voice Response System at 1-877-328-7098.
For members identified as having North Dakota traditional Medicaid coverage, you may submit the claims using one of the following options:
If any of the claims will not meet the North Dakota Medicaid requirements for timely filing, these claims must be submitted with the remittance advice you received from us showing the date the claim was re-adjudicated or denied for Medicaid Expansion coverage by Sanford Health Plan.
Sanford Health Plan participating providers are required to submit claims on members’ behalf. Claims should be submitted to Sanford Health Plan electronically using Payor ID 91184. We encourage you to transmit claims electronically for faster reimbursement and increased efficiency (Please see Provider EDI Resources in the provider manual or on the website for more information). Accepted claims forms are a standard CMS, UB or ADA claim. Submitting these forms with complete and accurate information ensures timely processing of your claim. All claims should be submitted using current coding and within 180 days, or as defined in your contract even if the member has not exceeded their deductible or copay amounts.
If you do not wish to file claims electronically, paper claims can be mailed to:
Sanford Health Plan Claims Department
PO Box 91110
Sioux Falls, SD 57109-1110
To improve our turnaround time and accuracy of paper claim processing, we use a scanning procedure using the Smart Data Solutions (SDS) system. It is important for you to know that the SDS system uses optical character recognition (OCR). Therefore, when OCR is used, your provider name must match our records in order for the system to correctly identify the “pay to” information. If a mismatch occurs, or if the claim cannot be read, you will receive a letter from SDS asking you for the missing or illegible information. A prompt response will prevent further delay in processing your claim.
When sending paper claims, please follow these guidelines:
A corrected claim is defined as a re-submission of a claim, such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review the processing of a claim. If you need to submit a corrected claim due to an error or change on an original submission, you can do so electronically or by paper. Corrected claims must be received within 60 days of the date of initial processing as indicated on the Explanation of Payment.
Voided claims are defined as a claim needing to be recouped and no reprocessing is necessary. The entire claim must match the original, with the exception of the claim frequency code and reference to the Sanford Health Plan original claim number.
When submitting corrected or voided claims, do not submit claims electronically and via paper at the same time. Medical records are not required with the submission of a corrected claim and are only needed when specifically requested from us.
Providers using Electronic Data Interchange (EDI) can submit professional and institutional corrected claims. The corrected Claim needs to contain the adjusted coding to help us identify and process the claim accurately.
Corrected claims filed electronically should be submitted with ALL service line items.
Corrected or voided claims submitted by paper need to be clearly identified as “CORRECTED CLAIM” or “VOIDED CLAIM” at the top of the claim form. If you are correcting or voiding a UB-04 claim, use appropriate type of bill type of XXX7 or XXX8 in box 4. If you are correcting or voiding a CMS claim, use appropriate resubmission code of “7” for a corrected claim or “8” for a voided claim and reference the original claim number that you are correcting or voiding in box 22 of the form.
Sanford Health Plan provides a variety of EDI resources for both professional and institutional claims to increase efficiency, track claim status, decrease errors, expedite cash flow, and reduce costs.
To review these forms, trading partner agreement and companion guides, CLICK HERE. Contact our EDI department if you have questions when completing the forms.
Sanford Health Plan exchanges data with several vendors and clearinghouses. Trading Partners who want to exchange data electronically with Sanford Health Plan will need to complete our Trading Partner Agreement. For further information or to download the Trading Partner Agreement and our EFT Enrollment Instructions, visit our website at sanfordhealthplan.com/providers/edi-resources.
Physicians and Allied Health Professionals should use the Center of Medicaid and Medicare Services (CMS) form 1500 to bill for medical services. Please follow the link for detailed instructions on how to correctly fill out the CMS 1500 form.
Field |
Description and Information |
Mandatory or Optional |
1 |
Type of insurance– check appropriate box. |
Optional |
1a |
Insured’s ID Number –Enter the member’s 9 digit number as it appears on their Sanford Health Plan ID card. |
Required |
2 |
Patient’s name-Enter the name of the member as it is on the ID card. |
Required |
3 |
Patient’s birth date and check |
Required |
4 |
Insured’s name- The name of the policy holder |
If applicable |
5 |
Patient’s complete address and phone number. |
Required |
6 |
Patient relationship to insured. |
If applicable |
7 |
Insured’s address. |
Not required |
8 |
Patient status. |
Not required |
9a-d |
Other health insurance coverage-Identify other group coverage for accurate coordination of benefits. If the patient has no other group coverage, enter NONE |
Not required |
10 a-c |
Is patient’s condition related to coverage for employment, auto or other accident related claims? |
Not required |
10d |
Reserved for local use. |
Not required |
11a-b |
Insured’s information– Name, policy/group number, employer, school name, insurance plan/program name. |
Not required |
11c |
For Medicare crossover claims, enter the Medicare Carrier Code. |
If applicable |
11d |
Is there another health benefit plan? Check yes or no. |
Required |
12 |
Patient’s signature and date. |
Not required |
13 |
Insured signature. |
Not required |
14 |
The date of first symptom for current illness, injury or last menstrual period for pregnancy. |
Required |
15 |
The date the same or a similar illness. |
Not required |
16 |
Dates patient unable to work in current occupation. |
Not required |
17 |
Name of referring physician. |
If applicable |
17a | ID number of referring physician-enter state medical license number. | If applicable |
17b | Enter referring provider's NPI number | If applicable |
18 | Hospitalization dates related to current services. Additional claim information | If applicable |
19 | Additional claim information | If applicable |
20 | Outside lab - check yes when diagnostic test was performed by any entity other than the provider billing the service | If applicable |
21 | Enter the patient's diagnosis or condition. Use ICD-10 code and use the highest level of specificity. | Required |
22 | Resubmission Code | If applicable |
23 | Prior authorization number | If applicable |
24a | Dates of service | Required |
24b | Enter code for place of service | Required |
24c | Emergency indicator | If applicable |
24d | Procedures, service or supplies - Enter the applicable CPT or HCPCS code(s) and modifiers in this section. | Required |
24e | Diagnosis pointer - enter the diagnosis code number from box21 that applies to the procedure code in 24 d. | Required |
24f | Charges - Enter the charge in dollar amount format for each listed service. If the item is a taxable medical supply, include the applicable state and county sales tax. | Required |
24g | Days or Units - Enter the number of medical visits, procedures, units of service, oxygen volume etc. Do not leave blank. | Required |
24h | EPSDT Family Plan - Enter code 1 or 2 if the services rendered are related to family planning (FP). Enter code 3 if the services rendered are Child Health and Disability Prevention screening related. |
If applicable |
24i | ID Qualifier |
If applicable |
24j | Rendering Provider ID#/NPI - Enter the rendering provider's NPI number. | If applicable |
25 | Federal Tax ID Number - Enter the Federal Tax ID Number for the billing provider. | Required |
26 | Patient's account number | Optional |
27 | Accept assignment | Not required |
28 | Total charges for services | Required |
29 | Amount paid | If applicable |
30 | Balance due - Enter the difference between the total charges for services and the amount paid. | If applicable |
31 | Signature of physician or supplier including credentials. | Required |
32 | Service facility location information - Enter the name, address, city, state and zip code of the location where the services were rendered. | Required |
32a | NPI Number - Enter the NPI number where the services were rendered. | Required |
32b | Other ID number | If applicable |
33 | Billing provider info and phone number - Enter the provider name, address, city, state, zip code and telephone number. | Required |
33a | NPI number - enter the billing provider's NPI | Required |
33b | Other ID number | Required |
Commonly known as UB-04, this form is used by institutional providers to bill payors including Sanford Health Plan. Examples of institutional providers include and are not limited to the following:
UB-04/CMS-1500 Instructions:
Field location UB-04 | Description | Inpatient | Outpatient |
1 | Provider Name and Address | Required |
Required |
2 | Pay-to Name and Address | Situational |
Situational |
3a | Patient Control Number | Not Required | Not Required |
3b | Medical Record Number | Optional | Optional |
4 | Type of Bill | Required | Required |
5 | Federal Tax Number | Required | Required |
6 | Statement Covers Period | Required | Required |
7 | Future Use | N/A | N/A |
8a | Patient ID | Situational | Situational |
8b | Patient Name | Required | Required |
9 | Patient Address | Required | Required |
10 | Patient Birthdate | Required | Required |
11 | Patient Sex | Required | Required |
12 | Admission Date | Required | Required, if applicable |
13 | Admission Hour | Required | Not Required |
14 | Type of Admission/Visit | Required | Required |
15 | Source of Admission | Required | Not Required |
16 | Discharge Hour | Required | Not Required |
17 | Patient Discharge Status | Required | Required |
18-28 | Condition Codes | Required, if applicable | Not Required |
29 | Accident State | Situational | Not Required |
30 | Future Use | Not Required | Not Required |
31-34 | Occurrence Codes and Dates | Required, if applicable | Required, if applicable |
35-36 | Occurrence Span Codes and Dates | Required, if applicable |
Required, if applicable |
37 | Future Use | Not Required | Not Required |
38 | Responsible Party Name and Address | Required | Required |
39-41 | Value Codes and Amounts | Required, if applicable | Required, if applicable |
42 | Revenue Code | Required | Required |
43 | Revenue Code Description | Required | Required |
NDC Code | Required, if applicable | Required, if applicable | |
44 | HCPCS/Rates | Required, if applicable | Required, if applicable |
45 | Service Date | N/A | Required |
46 | Units of Service | Required | Required, if applicable |
47 | Total Charges (By Rev. Code) | Required | Required |
48 | Non-Covered Charges | Not Required | Not Required |
49 | Future Use | N/A | N/A |
50 | Payer Identification (Name) | Required | Required |
51 | Health Plan Identification Number | Situational | Situational |
52 | Release of Info Certification | Required | Required |
53 | Assignment of Benefit Certification | Not Required | Not Required |
54 | Prior Payments | Required, if applicable | Required, if applicable |
55 | Estimated Amount Due | Required | Required |
56 | NPI | Required | Required |
57 | Other Provider IDs | Optional | Optional |
58 | Insured's Name | Required | Required |
59 | Patient's Relation to the Insured | Required | Required |
60 | Insured's Unique ID | Required | Required |
61 | Insured Group Name | Optional | Optional |
62 | Insured Group Number | Optional | Optional |
63 | Treatment Authorization Codes | Required, if applicable | Required, if applicable |
64 | Document Control Number | Optional | Optional |
65 | Employer Name | Not Required | Not Required |
66 | Diagnosis/Procedure Code Qualifier | Required, if applicable | Required, if applicable |
67 | Principal Diagnosis Code/Other Diagnosis Codes | Required | Required |
68 | Future Use | N/A | N/A |
69 | Admitting Diagnosis Code | Required | Not Required |
70 | Patient's Reason for Visit Code | Not Required | Required, if applicable |
71 | PPS Code | Required | Not Required |
72 | External Cause of Injury Code | Required, if applicable | Required, if applicable |
73 | Future Use | N/A | N/A |
74 | Principal Procedure Code/Date | Required, if applicable | Required, if applicable |
75 | Future Use | N/A | N/A |
76 | Attending Name/ID-Qualifier 1G | Required | Required |
77 | Operating ID | Required, if applicable | Required, if applicable |
78-79 | Other ID | Required, if applicable | Required, if applicable |
80 | Remarks | Required, if applicable | Required, if applicable |
81 | Code-Code Field/Qualifiers | ||
*0-A0 | N/A | N/A | |
*A1-A4 | Situational | Situational | |
*A5-AB | N/A | N/A | |
AC-Attachment Control Number | Situational | Situational | |
AD-B0 | N/A | N/A | |
*B1-B2 | Situational | Situational | |
*B3 | Required | Required |
Claims must be submitted within the filing period of 180 days from date of service or as defined in your contract. For inpatient services, timely filing begins from the date of discharge. Claims submitted outside of the filing period will be denied due to untimely filing. Charges denied for untimely filing are not to be billed to the member, but must be written off. For North Dakota Medicaid Expansion members, providers have 365 days from the date of service to submit claims.
We reimburse providers for “clean” claims within 30 calendar days of the receipt of the claim. Clean claims are those claims not requiring additional information before processing.
We will respond within 60 days of receipt for claims requiring additional information before processing (i.e. accident details, or other coverage information). If you do not receive an Explanation of Payment (EOP) from the Plan within the 60 days from the claims filing date, it is advisable to check the status through your secure provider account or by calling Customer Service.
No legal action may be brought to recover under this provision within 180 days after the claim has been received as required by your provider contract. No action to recover member expenses may be brought forth after four years from the time the claim is processed.
If the member fails to show their ID card at the time of service and you bill the wrong plan, then the member may be responsible for payment of the claim after the timely filing period has expired. Sanford Health Plan will only process claims with this denial at your request. Both you and the Member will receive an EOP and Explanation of Benefits (EOB) showing this denial. At this point, you accept responsibility for settling payment of the claim with the Member.
Sanford Health Plan processes over-payments by taking deductions on future claims. You may return the overpayment directly to Sanford Health Plan, but it will only be accepted if the overpayment has not already been offset by other claims. If the overpayment remains outstanding for more than 90 days, our Finance Department will send you a letter requesting payment.
If Sanford Health Plan has paid a claim in error, you may return the check or write a separate check for the full amount paid in error. A copy of the remittance advice, supporting documentation noting reason for the refund should be included with the refund.
Refunds should be sent directly to the Finance Department at this address:
Attn: Finance Department Sanford Health Plan
PO Box 91110
Sioux Falls, SD 57109-1110
Sanford Health Plan will pay the provider when a member receives covered services from a participating provider (physician, hospital, facility, dentist, etc.). Contracted providers agree to accept negotiated fee schedules as reimbursement in full for covered services provided to members. Provider offices may collect copay, estimated deductible and coinsurance at the time of service. Any non-covered service can also be collected.
Participating providers are not allowed to bill members the difference between the amount charged by the provider and the pre-negotiated Sanford Health Plan allowable reimbursement. The difference between the charged amount and the allowed amount is considered a provider write off. Services not covered by Sanford Health Plan guidelines will be the responsibility of the member. This excludes, but is not limited to, services denied for untimely filing or services medically necessary.
For ND Medicaid Expansion, as of January 1, 2018, to be considered a network provider, the following must be applicable: contracted with Sanford Health Plan; and Provider must be enrolled with the ND DHS Medicaid program as being affiliated with Sanford Health Plan; and Provider is located within the state of ND or one of the counties that border North Dakota in Minnesota, South Dakota and Montana. Federal regulations [42 CFR §438.602(b)] requires Sanford Health to confirm enrollment with ND DHS prior to payment for dates of service after January 1, 2018. Enrollment with the ND DHS Medicaid program does not require a provider to render services to ND Fee-for-Services recipients. North Dakota Medicaid Expansion enrollment guidance for providers is available HERE. Any services provided to ND Medicaid Expansion recipients not meeting these conditions will deny. Through Senate Bill (SB) 2012, the 2019 North Dakota (ND) Legislative Assembly reauthorized the Medicaid Expansion program for the 2019-2021 biennium. SB 2012 directed the Medicaid Expansion Managed Care Organization (MCO) to reimburse providers within the same provider type and specialty at consistent levels and with consistent methodology.
Providers acknowledge and agree that they shall allow for certain changes to the terms of the Agreement regarding the Medicaid Expansion line of business. These changes may include, but are not limited to, reimbursement rates and are the direct result of action taken by the North Dakota legislature and/or a mandate from the North Dakota Department of Human Services. The Health Plan shall implement such changes (including reimbursement rates) in accordance with the timeline(s) provided by the North Dakota Legislature or the North Dakota Department of Human Services.
A non-participating provider is defined as a Practitioner and/or Provider who has not signed a contract with Sanford Health Plan, directly or indirectly, and not approved by Sanford Health Plan to provide Health Care Services to Members with an expectation of receiving payment, other than Coinsurance, Copays, or Deductibles, from Sanford Health Plan. When a member receives covered services from a non-participating provider, Sanford Health Plan will allow the Sanford Health Plan’s established maximum allowed amount. Maximum allowed amount is the amount established by Sanford Health Plan using various methodologies for Covered Services and supplies. Sanford Health Plan’s Maximum Allowed Amount is the lesser of:
Sanford Health Plan accepts claims directly from non-participating providers. If the non- participating provider does not submit claims to Sanford Health Plan, members may submit a member claim form. Claims, whether directly from providers or from members, must be submitted within 180 days (365 days for ND Medicaid Expansion) from the date of service or date of inpatient discharge. The member may contact Sanford Health Plan’s Customer Service Department to discuss how to submit the required information. Payment will be sent directly to the Provider. If the Provider refuses direct payment, the member will be reimbursed the maximum allowed amount for the service. However there is an exception for North Dakota Medicaid Expansion members; Per federal and state regulations, members cannot be reimbursed directly by the Plan for costs paid directly to Providers.
Only the maximum allowed amount is applied to the Member’s benefits. SHP may take additional reductions based on the member’s benefits. The payment reduction does not apply toward the member’s out-of-pocket maximum amount.
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.
Modifiers are two digit codes which are used to indicate when a service or procedure has been altered or modified by some specific circumstance without altering or modifying the basic definition of the CPT code. The use of some modifiers may affect reimbursement. The following chart lists modifiers that Sanford Health Plan recognizes for pricing increases or decreases.
Sanford Health Plan utilizes Optum Claims Editing System software to apply correct coding and standardization for editing of professional claims. We consider and apply industry standard edits as outlined by National Correct Coding Initiative, American Medical Association and Centers for Medicare & Medicaid Services guidelines. Authorizations or referrals do not override system claim edits. Edits made to claims are considered to be a provider adjustment and not billable to the member. Edits will be applied to both participating and non participating providers.
Services are considered inpatient when a member has been admitted to the hospital (exception: less than 24 hours). All charges incurred during the hospital stay are to be submitted timely for reimbursement. The Plan includes the day of admission, but not the day of discharge when computing the number of facility days provided to a Member. Timely filing begins from the date of discharge.
Interim claims, sometimes referred to as split- bills, allow hospitals to submit a claim for a portion of the patient’s inpatient stay. They contain bill types 112, 113 and 114.
Interim claims are accepted by Sanford Health Plan for bill types 112 (first claim in series) where the billed amount exceeds the greater of $100,000 or the contracted outlier threshold where applicable. Continuing claims in the series will be accepted for bill type 113 if the billed amount exceeds $100,000 per continuing claim. Claims received with bill type 114 will be accepted as final bill with the remaining billed charges. Interim claims not meeting these criteria will be denied. Provider may resubmit interim claims under this criteria or file all charges with bill type 111 (admission through discharge).
Sanford Health Plan uses Optum’s DRG grouper software for grouping and assigning a CMS MS-DRG code to each inpatient claim for payment purposes where the provider contract uses DRG methodology. Claims that are ungroupable or group to an invalid DRG will be denied. The Plan will use the grouper version released by CMS annually in October, or as specified in your contract, effective on the date of admission.
Skilled Nursing Facility (SNF) is a facility, either freestanding or part of a hospital that accepts patients in need of rehabilitation and/or medical care that is of a lesser intensity than that received in a hospital. Sanford Health Plan reimburses providers based on the levels of care billed. Providers are required to bill the appropriate level of care for which services were provided. The following levels of care and services shall be made available to members in accordance with Plan policies.
Level 1: Semi private room and board; general nursing up to three hours of nursing per patient day (PPD) Including:
Level 2: All Level I services and supplies and nursing hours greater than 3.5 and up to 5.0 hours of Nursing care per patient per day (PPD) including:
Level 3: All Level I and II services and supplies and all general nursing services that require 5.0 – 6.5 Nursing hours per patient per day including:
*Complex care is beyond routine skilled care where the client needs a higher level of monitoring and/or nursing intervention.
DRG categories that are candidates for subacute include:
Level 4: Clients that are outside the perimeters of Levels 1-3 are reviewed on a case by case basis for admission. Admission would be dependent on the Provider’s competencies to administer the appropriate care and upon an agreement for reimbursement. (i.e. all ventilator care with and without weaning; nursing hours are greater than 6.5 PPD)
Providers will receive a one time claim reconsideration if requests are submitted within 180 days of the determination (original EOP) date. After this time, reconsideration requests will no longer be accepted. The Reconsideration Request Form, at sanfordhealthplan.com/providers/forms and required documentation must be submitted or the request will be returned unprocessed. Reconsideration requests can also be submitted online in the Provider Portal at sanfordhealth.org/Provider Select “InBasket” from the Menu bar, choose “New Message” and then “Provider Communication.” A window with a drop down box will appear, at which time “Claim Reconsideration” should be chosen. Documentation (i.e., completed claim reconsideration form, copy of claim) is required for submission.
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.
Sanford Health Plan participating providers are contractually obligated to file claims within 180 days. For North Dakota Medicaid Expansion member, providers can file claims within 365 days. Sanford Health Plan processes a “clean claim” within 30 days of receipt of the claim and 60 days for a “non-clean” claim. In North Dakota, Sanford Health Plan will pay clean claims within 15 days of receipt of the claim. Therefore, all claims are to be paid or processed within 60 days. Required documentation includes screen prints from the billing system showing the date the claim was sent to the Plan. If claims are filed electronically, required documentation includes a dated screen print, with the documented name of the clearinghouse being used, of the claim being accepted without error by the Plan.
Detecting and preventing fraud, waste, and abuse (FWA) is the responsibility of everyone. Sanford Health Plan encourages providers, members, affiliates, facilities, vendors, consultants and contractors to report any suspected Fraud, Waste or Abuse to the SHP Compliance Officer directly by calling, emailing or anonymously through the hotline.
Sanford Health Plan will protect its corporate assets and the interests of its members, employers, and providers against those who knowingly and willingly commit fraud or other wrongful acts. We will identify, resolve, recover funds, report, and when appropriate, take legal actions, if suspected fraud, waste, and/or abuse have occurred.
A provider’s submission of a claim for payment also constitutes the provider’s representation the claim is not submitted as a form of, or part of, fraud, waste and abuse as listed below, and is submitted in compliance with all federal and state laws and regulations. The definitions of fraud, waste and abuse and examples follow.
Provider is responsible for providing guidance to employees, independent contractors, and subcontractors regarding how to report potential compliance issues. Provider is responsible for promptly addressing and correcting all issues brought to your attention.
Providers are responsible for, and these provisions likewise apply to, the actions of their staff members and agents. Sanford Health Plan routinely verifies charges billed are in accordance with the guidelines stated in this payment policy and are appropriately documented in the member’s medical record. All payments are subject to prepayment audits, post-payment audits and retraction of over-payments. Any amount billed by a provider in violation of this policy and paid by Sanford Health Plan constitutes an overpayment and is subject to recovery. A provider may not bill members for any amounts due resulting from a violation of this policy.
Prevention Techniques
Fraud, waste and abuse can expose a Provider, contractor, or subcontractor to criminal and civil liability. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.
Provider is responsible for implementing methods to prevent fraud, waste, and abuse. Listed below are some common prevention techniques. This list is not meant to be all-inclusive.
How to report?
Sanford Health Plan requires everyone to exercise due diligence in the prevention, detection and correction of Fraud, Waste and Abuse (FWA).
Sanford Health Plan promotes an ethical culture of compliance with all State and Federal regulatory requirements, and mandates the reporting of
any suspected or actual FWA to the Sanford Health Plan Compliance. The compliance team can be reached by emailing compliancehotline@sanfordhealth.org or calling the anonymous Compliance Hotline: (800) 325-9402.
Definitions and Examples:
Fraud is defined as: knowingly and willingly executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.
Health care fraud examples include but are not limited to the following:
Waste is defined as:
practices which directly or indirectly result in unnecessary costs such as overusing services. It is the misuse of resources.
Abuse is defined as:
the practice of directly or indirectly, result in unnecessary costs and includes any practice inconsistent with providing patients with medically necessary services meeting professionally recognized standards.
Examples of abuse include:
Accident information is essential for determining which insurance company has primary responsibility for a claim. Common situations where another insurance company may be liable for paying claims are motor vehicle accidents, or injuries at work. Sanford Health Plan contracts with Optum to contact members about claims which another party may be liable.
Claims are sent to Optum based on diagnosis codes. Members are contacted by Optum to investigate if a third party is liable. Claims will be denied if another party is responsible for the payment of the claim or there is no response from the member.
Optum’s process is as follows. Sanford Health Plan will electronically send claim information to Optum daily. Optum then identifies possible accident related claims and calls the member three times by phone. If they are unable to reach them, they send out an inquiry questionnaire (IQ) and cover letter. The cover letter explains the relationship between Sanford Health Plan and Optum and why the information is needed. The IQ inquires whether the claim in question is due to an accident and gives the member a choice of providing the information to Optum on the questionnaire, or by calling Optum’s toll-free number and talking directly to an Optum representative.
Once Optum has sent the IQ, they wait ten days for a response. If after ten days they have no response from the member, they send out a close out letter and wait another ten days for a response. The close out letter explains that Optum has been unsuccessful in their attempts to reach the member and will be required to notify Sanford Health Plan to deny the claim(s) in question.
If Optum has not received a response within this second 10-day period, they send advice to Sanford Health Plan to deny the claims in question for lack of information. This process normally takes approximately 25 days assuming Optum does not receive a response. Optum will identify about 10% of Sanford Health Plan’s claims in 24 hours, 80% in 8 calendar days, 90% in 14 calendar days and 99% in 25 days. Optum’s toll free number that members can call to relay the requested information is (800) 529-0577.
Coordination of Benefits (COB) is a provision that allows members to be covered by more than one health benefit plan and to receive up to 100% coverage for medical services. If a member is covered by another health plan, insurance, or other coverage arrangement, then Sanford Health Plan and/or insurance companies will share or allocate the costs of the member’s health care by a process called Coordination of Benefits. Sanford Health Plan follows all statutory and administrative laws concerning coordination of benefits, as applicable to the state in which the plan is domiciled. The member has two obligations concerning Coordination of Benefits:
The order of benefits determination rules govern 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 expenses. The plan that pays after the primary plan is called the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans do not exceed 100 percent of the total allowable expense.
The Plan determines its order of benefits using the first of the following rules which applies:
The plan that covers the person as a employee, policyholder, retiree, member or subscriber (that is other than as a dependent) is the primary plan. The plan that covers the individual as a dependent is the secondary plan. If the person is also a Medicare beneficiary, Medicare is:
For a dependent child whose parents are married or living together (married or not) unless there is a court order stating otherwise, the order of benefits is: •
For a dependent child whose parents are not married, separated (whether or not they ever have been married) or are divorced, the order of benefits is:
The order of benefits shall be determined using the rule for “Dependent Child Who Has Parents Living Together” as if the individuals were the parents of the child.
If a person whose coverage is provided under a right of continuation pursuant to a federal or state law also is covered under another plan, the following shall be the order of benefit determination:
If the preceding rules do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan.
If the preceding rules do not determine the primary plan, the allowable expenses shall be shared equally between the plans meeting the definition of plan under this regulation. In addition, this plan will not pay more than it would have paid had it been primary.
When Sanford Health Plan is secondary, we shall reduce benefits so that the total benefits paid or provided by all plans for any claim or claims do not exceed more than 100 percent of total allowable expenses. In determining the amount of a claim to be paid by Sanford Health Plan, we calculate the benefits that we would have paid in the absence of other insurance and apply that calculated amount to any allowable expense that is unpaid by the primary plan. We may reduce our payment by any amount that, when combined with the amount paid by the primary plan, exceeds the total allowable expense for that claim.
Medicare benefits provisions apply when a member has health coverage under Sanford Health Plan and is eligible for insurance under Medicare Parts A and B, (whether or not the member has applied or is enrolled in Medicare). This provision applies before any other coordination of benefits provision of Sanford Health Plan.
If a provider has accepted assignment of Medicare, Sanford Health Plan determines allowable expenses based upon the amount allowed by Medicare. Our allowable expense is the Medicare allowable amount. We will pay the difference between what Medicare pays and our allowable expense.
The Plan shall coordinate information relating to prescription drug coverage, the payment of premiums for the coverage, and the payment for supplemental prescription drug benefits for Part D eligible individuals enrolled in a Medicare Part D plan or any other prescription drug coverage. Sanford Health Plan will make this determination based on the information available through CMS.
A Covered Individual’s eligibility for any State Medicaid benefits will not be taken into account in determining or making any payments for benefits to or on behalf of the member. Any such benefit payments will be subject to the applicable State’s right to reimbursement for benefits it has paid on behalf of the Covered Individual, as required by such state’s Medicaid program; and Sanford Health Plan will honor any subrogation rights the State may have with respect to benefits that are payable. When an individual covered by Medicaid also has coverage with Sanford Health Plan, Medicaid is the payer of last resort. If also covered under Medicare, Sanford Health Plan pays primary, then Medicare, and Medicaid is tertiary. See provisions below on Coordination of Benefits with TRICARE, if a member is covered by both Medicaid and TRICARE.
Generally, TRICARE is the secondary payer if the TRICARE beneficiary is enrolled in, or covered by, any other health plan to the extent that the service provided is also covered under the other plan. Sanford Health Plan pays first if an individual is covered by both TRICARE and Sanford Health Plan, as either the Member or Member’s Dependent; and a particular treatment or procedure is covered under both benefit plans. TRICARE will pay last; TRICARE benefits may not be extended until all other double coverage plans have adjudicated the claim. When a TRICARE beneficiary is covered under Sanford Health Plan, and also entitled to either Medicare or Medicaid, Sanford Health Plan will be the primary payer, Medicare/Medicaid will be secondary, and TRICARE will be tertiary (last). TRICARE-eligible employees and beneficiaries receive primary coverage under this Certificate of Coverage in the same manner, and to the same extent, as similarly situated employees of the Plan Sponsor (Employer) who are not TRICARE eligible.
For North Dakota Medicaid Expansion members, NDME is the primary payer AND TRICARE is secondary payor. When a TRICARE beneficiary is covered under this plan, and also entitled to Medicaid Expansion, NDME will be the primary payer, absent other coverage, and TRICARE will be secondary. TRICARE-eligible Members receive primary coverage under this Plan’s provisions in the same manner, and to the same extent, as similarly situated Members who are not TRICARE eligible.
The Plan has primary responsibility for the claims of a Member:
The Plan has secondary responsibility for the claims of a Member:
Multiple surgeries are defined as multiple procedures performed at the same session by the same provider. Sanford Health Plan allowances are reduced for multiple surgical procedures. Multiple surgical procedures should be identified with a modifier 51. Multiple surgery fees should not be billed pre-cut. Sanford Health Plan uses the following payment structure for multiple surgery claims.
If a procedure is performed on both sides of the body it is considered to be bilateral. Bilateral procedures are identified with a modifier 50. Bilateral procedures should be billed on one line. See the below example. Example: Bilateral procedures billed on one line (two services).
To ensure accurate payment, please make sure to bill the full billed amount versus billing with the pre-cut amount. We are not able to recognize a claim pre-cut, and our system will cut according to the bilateral procedures guidelines.
Assistant at Surgery claims can be identified by modifier 80, 81, 82 or AS. Claims with modifiers 80, 81, 82 or AS will be adjudicated according to the CMS guidelines for Assistant at Surgery and should not be billed pre-cut. Surgeries that allow an Assistant at Surgery will be reimbursed 20% of the applicable allowable.
The list of codes eligible for Assistant at Surgery reimbursement will follow the Assistant at Surgery indicator published by CMS in the National Physician Fee Schedule Relative Value File, released annually in the Fall prior to the effective date in January. Sanford Health Plan will not apply any CMS mid-year updates.
Claims will be denied for those surgeries that do not require an Assistant at Surgery and these charges should not be billed to the member. Participating providers are contractually obligated to write off Assistant at Surgery fees that are not covered by Sanford Health Plan. Requests for reconsideration of denied Assistant at Surgery charges must be received within 60 days of the denial date on the EOP and can be submitted using the claim reconsideration form found online. Please include a reference to the claim number, code(s) being asked for reconsideration and a copy of the medical record.
Claims must be submitted within 180 days from the date of delivery. After this time frame has expired, claims will no longer be reviewed. Required documentation includes date of delivery.
A newborn is eligible to be covered from birth. Members must complete and sign an enrollment application form requesting coverage for the newborn within 31 days of the infant’s birth. Because of this timeframe to add newborn dependents to a policy, providers should not file claims prior to the 31 days of an infant’s birth. Claims received prior to the newborn being added to a policy may be denied or rejected electronically as “member not eligible.” Providers will need to re-file claims timely after the newborn is enrolled for proper claims processing and reimbursement.
Never events, avoidable hospital conditions, and serious reportable events are defined in the following table. The definitions have been developed by the National Quality Forum and CMS in collaboration with multiple partners, including the AMA.
Sanford Health Plan does not provide reimbursement for services associated with a Never Event, Avoidable Hospital Condition, or Serious Reportable Event when permitted by contract. Providers are not permitted to bill members for these services and must notify the plan, within five days of the occurrence.
The following policy(s) are referenced in this section and are available for review in the “Quick Links” section under “Policies & Medical Guidelines” at sanfordhealthplan.com/providerlogin.
Site of Service Differential: Some professional services may be provided either in a facility or a non-facility setting. When a professional service is provided in a facility, the costs of the clinical personnel, equipment, and supplies are incurred by the facility, not the physician practice. For this reason, reimbursement for professional services provided in a facility may be lower than if the services were performed in a non-facility setting. This difference in reimbursement, based on where the professional service is performed, is referred to as a “site of service differential.”
In accordance with CMS guidelines, professional providers will be reimbursed based on the site of service where the selected procedures are performed. Only codes that have a site of service differential are included in Sanford Health Plan’s list of applicable procedures for differential reimbursement. This only applies to provider contracts that include Site of Service differential.
The CPT® codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Sanford Health Plan uses CMS’s list of procedure codes where there is a difference between the facility and non-facility RVUs that are in effect at the time Sanford Health Plan’s current fee schedule year was implemented. Sanford Health Plan will review the list of site of service procedures codes and places of service upon contract renewal.
The table below includes current national place of service code set information that identifies the facility and non-facility designations for each code.
Anesthesia is the administration of a drug or anesthetic agent by an anesthesiologist or certified registered nurse anesthetist (CRNA) for medical or surgical purposes to relieve pain and/ or induce partial or total loss of sensation and/or consciousness during a procedure. Sanford Health Plan covers the administration of anesthesia for medically necessary services rendered to Sanford Health Plan members.
Medically directed anesthesia: Sanford Health Plan utilizes the base value unit, as reported by CMS, and the actual time units necessary to perform the anesthesia service to determine its reimbursement amount. The physician and the CRNA shall append the appropriate modifiers to all anesthesia services provided. Services submitted with medical direction or supervision, modifiers AD, QK, QX, or QY, will be reimbursed at 50% of the allowed amount, due to the supervision/services shared between two providers. Time-based anesthesia services must be reported with actual anesthesia time in one-minute increments. Anesthesia time calculates a unit for every 15 minute interval, rounding up to the next unit for 8-14 minutes, rounding down for 1 to 7 minutes. Sanford Health Plan will not reimburse for services billed by anesthesia students.
Billing instructions:
Time-Based Anesthesia claims are typically paid based on the following:
([Base Unit + Time Units] x Anesthesia Conversion Factor) x Modifier Percentage
Labor Epidurals - Time related to neuraxial labor anesthesia is different than operative anesthesia according to the American Society of Anesthesiologists (ASA). The number of minutes and charges billed should only reflect the time the anesthesiologist or CRNA is present for preparation, insertion and monitoring of the epidural which should coincide with the intensity and direct time involved for performing and monitoring neuroaxial labor analgesia. Complications that are present and that require the constant attendance of the anesthesiologist or CRNA should be billed appropriately with time unites that reflect the full time the epidural catheter is in place but should not be the standard. Consistent with a method described in the ASA guidelines, Sanford Health Plan will cap the Time Units used to reimburse labor epidurals (CPT code 01967) at 5 Units (75 minutes) unless constant attendance by an anesthesiologist or CRNA is medically necessary.
([Base Unit + Time Units (Not to Exceed 5)] x Anesthesia Conversion Factor) x Modifier Percentage
Sanford Health Plan separately reimburses outpatient pre-labor monitoring services based on individual provider contract percent of charges. The following billing and claim submission requirements will apply:
Billing instructions:
Additional claims criteria:
Services are considered inpatient when a member has been admitted to the hospital (exception: less than 24 hours). All charges incurred during the hospital stay are to be submitted timely for reim- bursement. The Plan includes the day of admis- sion, but not the day of discharge when computing the number of facility days provided to a Member. Timely filing begins from the date of discharge.
Interim claims, sometimes referred to as split- bills, allow hospitals to submit a claim for a portion of the patient’s inpatient stay. They contain bill types 112, 113 and 114. Interim claims are accepted by Sanford Health Plan for bill types 112 (first claim in series) where the billed amount exceeds the greater of $100,000 or the contracted outlier threshold where applicable. Continuing claims in the series will be accepted for bill type 113 if the billed amount exceeds $100,000 per continuing claim. Claims received with bill type 114 will be accepted as final bill with the remaining billed charges. Interim claims not meeting these criteria will be denied. Provider may resubmit interim claims under this criteria or file all charges with bill type 111 (admission through discharge).
Sanford Health Plan uses Optum’s DRG grouper software for grouping and assigning a CMS MS- DRG code to each inpatient claim for payment purposes where the provider contract uses DRG methodology. Claims that are ungroupable or group to an invalid DRG will be denied. The Plan will use the grouper version released by CMS annually in October, or as specified in your contract, effective on the date of admission.
Skilled Nursing Facility (SNF) is a facility, either freestanding or part of a hospital that accepts patients in need of rehabilitation and/or medical care that is of a lesser intensity than that received in a hospital. Sanford Health Plan reimburses providers based on the levels of care billed. Skilled nursing services must be billed with the appropriate Rev code in box 42 of the UB-04 claim form for which services received prior authorization. Rev codes shall correspond to a level of care as defined in the following table:
The following levels of care and services are further defined and shall be made available to members in accordance with Plan policies.
Level 1: Semi private room and board; general nursing up to three hours of nursing per patient day (PPD) Including:
Level 2: All Level I services and supplies and nursing hours greater than 3.5 and up to 5.0 hours of Nursing care per patient per day (PPD) including:
Level 3: All Level I and II services and supplies and all general nursing services that require 5.0 – 6.5 Nursing hours per patient per day including:
DRG categories that are candidates for subacute include:
Level 4: Clients that are outside the perimeters of Levels 1-3 are reviewed on a case by case basis for admission. Admission would be dependent on the Provider’s competencies to administer the appropriate care and upon an agreement for reimbursement. (i.e. all ventilator care with and without weaning; nursing hours are greater than 6.5 PPD)
Home health care is a wide range of health care services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and considered just as effective as care received in a hospital or skilled nursing facility (SNF). Home health care services are billed using a combination of revenue codes, HCPCS codes and units. Units are calculated for every 15 minute interval for which services were rendered.
Hospice services are for those who are terminally ill (with six months or less to live). The goal of hospice is to provide comfort for terminally ill patients and their families, not to cure illness. Respite care is a very short inpatient stay given to a hospice patient so that the usual caregiver can rest. Hospice and respite services are to be billed with the appropriate revenue code in box 42 of the UB-04 claim form.
Sanford Health Plan implemented APC pricing methodology for outpatient service in 2016. We follow the general principles, billing, pricing, and edit guidelines of the Center for Medicare & Medicaid Services (CMS) outpatient prospective payment/ambulatory payment classifications (OPPS/APC’s) unless otherwise stated in individual contracts. APC methodology is used for covered outpatient services at Prospective Payment System hospitals and General Acute Care facilities.
Sanford Health Plan uses Optum’s EASYGroup™, ECM Pro, Client Hosted Web.Strat Rate Manager APC software to deliver Ambulatory Payment Classification (APC) pricing methodology for outpatient services billed via the UB-04 claim (or electronic equivalent) with bill types 13X or 14X. This product seamlessly integrates with Sanford Health Plans’ EPIC Tapestry host systems. We began using Ambulatory Payment Classification (APC) pricing methodology to help control cost and utilization of services. This is the result of a national trend in decreased inpatient volume and an increase in outpatient services. It is intended to provide an opportunity to level set for both the provider and payer, while reimbursing the provider for the resources utilized for the services.
APC pricing/methodology is not considered for:
Each HCPCS code for which separate payment is made under the OPPS is assigned to an APC group. The payment rate for an APC applies to all of the services assigned to the APC. APC payment rates are calculated using the following methodology: (Provider specific conversion factor x APC-specific weight). A hospital may receive a number of APC payments for the services furnished to a patient on a single day on the same claim; however, certain services are subject to discounting for multiple procedures. Services within an APC are similar clinically and with respect to hospital resource use.
Sanford Health Plan will follow CMS APC billing guidelines including:
Sanford Health Plan deviates from CMS on the following guidelines:
(Providers should not use HCPCS code A9270, non-covered item or service, as this is a member liable denial per benefit design.) Any take-home drugs or supplies without a specific code should be submitted on the generic revenue codes below:
For services submitted with a HCPCS code, reimbursement will be driven off of the OPPS status indicator associated with the procedure code submitted and will be reimbursed either at the fee schedule rate or the default percent of charges per the provider’s contract. Services submitted under one of the generic revenue codes above will be either packaged into the reimbursement for the other primary services on the claim that were paid under APC’s or they will be reimbursed at the default percent of charges per the provider’s contract.
Payment rules for Partial Hospitalization: Payment for outpatient mental health services will be based on Rev Codes or one of five H or S HCPCS codes below per individual contract language.
Codes mapped out of relevant OCE and paid at either fee schedule rate or default to percent of charge due to differences in demographic and benefit design.
Sanford Health Plan will follow CMS APC pricing rules including the following:
Sanford Health Plan will also apply the following guidelines:
The role of OCE is to edit claims for errors, notify Sanford Health Plan what action to take with a “problem” claim, assign payment categories/groups and pre-process data for APC pricing. Editing categories used in OCE include:
Due to OCE claim edits, your claim may be returned or denied.
APC Updates:
Sanford Health Plan will review updates released by CMS.
These updates may result from:
Updates include: Quarterly updates to:
Annual updates to:
1. The Plan will delay implementation of the quarterly update one calendar month to provide adequate time for review of CMS updates, configuration, and testing.
2. Claims received by the Plan during one month interim will be reimbursed according to the groupings, weights, and codes in the payment system at the time received which will reflect the previous quarter’s updates based on date of service.
Example: Claims submitted with January dates of service in January will be reimbursed according to the groupings, weights, and codes from the 4th quarter of the previous year
3. Claims received by the Plan after the one month delay will be reimbursed according to the updated file in the payment system at the time received based on date of service.
Example A: Claims submitted with February dates of service in February will be reimbursed according to the groupings, weights, and codes from the 1st quarter of that year.
Example B: Claims submitted with January dates of service in February will be reimbursed according to the groupings, weights, and codes from the 4th quarter of the previous year.
4. Claims incurred by the Plan during the one month interim will not be reprocessed by The Plan.
5. The Plan will reimburse any new codes according to the contracted Outpatient All Other Services % of charge for claims received by The Plan during one month delayed implementation.
6. For the January CMS update, the Plan will implement an adjustment factor budget neutral to the Plan based on the aggregate weight change between the new APC weights and the current weights derived from historical claims.
Sanford Health Plan Provider Contracting will send annual reimbursement notice that will include conversion factor and RCC.
We will provide notice of action plan in the event CMS has a delay in releasing updates.
We encourage providers to visit the following CMS website links for further details regarding APC claim processing.
Addendum A & B Updates where APC states codes are updated
General CMS Hospital Outpatient OPPS Information
National Correct Coding Initiative Edits/MUE’s:
Select facility outpatient services MUE table at the bottom of the page.