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:

1. Electronic Claim Submission – utilizing the North Dakota MMIS Web Portal found HERE. If needing to submit the remittance advice, indicate that there is a claims attachment and fax in documentation using the “MMIS Attachment Cover Sheet” (SFN 177) form which can be found HERE.
2. Paper Claim Submission – attach remittance advice to claim if needing to submit

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: 

• Print on a laser printer 
• If a dot matrix printer must be used, make sure it is legible 
• Use Courier New 10 point font for clean scanning.
• Use uppercase for optimal scanning.
• Ensure that clean character formation occurs when printing paper claims (i.e. one side of the letter/number is not lighter/darker than the other side of the letter/ number).
• Claim forms should be lined up properly
• Do not place additional stamps on the claim such as received dates, sent dates, medical records attached, resubmission, etc.
• Use an original claim form - not a copied claim form.
• Use a standard claim form (individually created forms have a tendency to not line up correctly, prohibiting the claim from scanning cleanly).
• The billing, servicing and/or rendering provider’s NPI must be included in the designated locations for accurate matching within the scanning and claim system.
• For a continued claim, please indicate “continued” in the appropriate box of the claim form so the claims can be kept together and whole.
• Do not place the total amount on each of the individual pages.

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.

• Enter Claim Frequency Type code (billing code) 7 for a replacement/correction, or 8 to void a prior claim, in the 2300 loop in the CLM*05.
• Enter the original claim number as processed by Sanford Health Plan in the 2300 loop in the REF*F8*.

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.

• 837 Health Care Claim Transactions Electronic Funds Transfer (EFT)
• 835 Health Care Claim Payment/Advice Transactions • 270/271 Real Time Transactions for Eligibility, Coverage, or Benefit Inquiry & Information
• 276/277 Real Time Transactions for Health Care Information Status Request and Response.

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.

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:

• Hospital 
• End Stage Renal Disease
• Hospices
• Comprehensive Outpatient Rehabilitation Facilities
• Community Mental Health Centers
• Federally Qualified Health Centers
• Skilled Nursing Facilities 
• Home Health Agencies 
• Outpatient rehabilitations clinics
• Critical Access Hospitals

UB-04/CMS-1500 Instructions:

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

1. Contact information for Sanford Health Plan 
2. Check / EFT #: Payment information identifying the Tax ID the payment was made under, the payment date and the total amount disbursed.
3. Date(s) of Service: Date the member was seen by healthcare provider/services were rendered.
4. Service Codes: CPT, HCPCS or Revenue Codes Billed. 
5. Number of Units: Quantity of service provided. 
6. Charged Amount: Total amount billed by the provider for the procedure or service rendered.
7. Allowed Amount: The negotiated rate for which is allowed for in-network providers. For out-of-network providers it is the maximum allowed amount.
8. Discount Amount: The amount deducted (discounted) from the charged amount based on contractual agreements.
9. TPP: A third party payer (TPP) is an entity, outside of Sanford Health Plan, which provides reimbursement to providers for services rendered to members.
10. Copayment: The fixed amount the member owes the provider at the time of service. This amount is not applied to the deductible or co-insurance. Provider can bill the member for this amount.
11. Deductible: The amount of the member’s deductible that has been applied to a covered service or procedure. Provider can bill the member for this amount.
12. Coinsurance: Amount of member’s coinsurance that has been applied to a covered service or procedure. Provider can bill member for this amount.
13. Member Liability: If present, amount the member is liable for on a non-covered service excluding copayment, deductible, and coinsurance. Provider can bill member for this amount. 
14. Provider Liability: If present, amount the provider may be liable for on a non-covered service excluding copayment, deductible and coinsurance. Members may not be billed this amount.
15. Reimbursed Amount: Payment received by the provider for rendering a medical service.
16. Reason code(s): Codes used to explain any claim financial adjustments, reductions or increases in payment. Descriptions will appear at the end of your explanation of payment.

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:

• the amount charged for a Covered Service or supply; or
• inside Sanford Health Plan’s Service Area, negotiated schedules of payment developed by Sanford Health Plan, which are accepted by Participating Practitioner and/or Providers; or
• outside of Sanford Health Plan’s Service Area, using current publicly available data adjusted for geographical differences where applicable: i. Fees typically reimbursed to providers for same or similar professionals; or ii. Costs for Facilities providing the same or similar services, plus a margin factor.

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.

• Non-Participating Provider Compensation (PC-032)

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:

• Wound Care
• State I and II pressure ulcers
• Incontinent care; bowel and bladder training
• Colostomy/Ilestomy care
• Foley catheter care (maintenance and irrigation); including teaching
• Insulin dependent diabetic care; including teaching
• Dressing changes
• Routine laboratory
• X-rays
• Pharmacy; (oral medications)
• Routine supplies
• Routine durable medical equipment (wheel chairs, walkers, canes, etc.)
• Respiratory therapy – 2 small volume nebulizers (Nursing Department)
• Low flow oxygen, 3 LPM or less
• Restorative therapy including ROM, functional maintenance

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: 

• Stage III and IV pressure ulcers
• Old tracheotomy care and supplies (2 or more suctionings per shift-3 shifts per day)
• NG, GI, G tube patient (enteral feeding pumps included)
• Simple IV therapy (hydration plus one medication is “simple”)
• Wound isolation not requiring a private room 
• Respiratory therapy 3 or more small volume (Nursing Department)
• PT/OT/ST once a day (minimum 2 fifteen minute units) up to one hour of therapy per day, 5 days per week including therapy evaluation

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: 

• Post-surgery care and monitoring every four hours
• Complex medical care*
• Complex IV management (multiple medications) NOTE: The costs of the IV medication is excluded from the per diem rate in excess of $35.00 PPD
• Rehabilitation (PT, OT, ST a combination of 1-3 hours per day BID) 
• New tracheotomy; including teaching

*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: 

• Pulmonary/Respiratory 
• Cardiac/Circulatory 
• Orthopedic 
• Gastrointestinal
• Pancreas, liver, gall bladder and spleen disease 
• Cancers and malignancies 
• Kidney, urinary tract
• Wound/skin
• Endocrine and metabolic disease 
• Neurological/spinal
• Infections
• Amputations
• Trauma

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.

• Claim Re-Considerations (PR-014)

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.

• Education related to Fraud, Waste and Abuse
• Validate all member ID cards prior to rendering service (Cross-checking with another form of government issued photo ID is a good practice.)
• Ensure accuracy when submitting bills or claims for services rendered
• Submit appropriate Referral and Treatment forms 
• Avoid unnecessary drug prescription and/or medical treatment
• Report lost or stolen prescription pads and/or fraudulent prescriptions 
• Screen all employees and contractors at time of hire/contract and monthly thereafter to prevent reimbursement of excluded and/or debarred individuals and/or entities. Two of the review resources are:
  • SAM– The Excluded Parties List System (“EPLS”) is maintained by the GSA, now a part of the System for Awards Management (“SAM”). The EPLS is an electronic, web- based system that identifies those parties excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non-financial assistance and benefits. The EPLS keeps its user community aware of administrative and statutory exclusions across the entire government, and individuals barred from entering the United States. sam.gov
  •  LEIE – List of Excluded Individuals and Entities list is maintained by HHS OIG and provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, Marketplace and all Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. exclusions.oig.hhs.gov

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: 

• Misrepresentation of the type or level of service provided
• Misrepresentation of the individual rendering service

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:

• Billing for unnecessary medical services
• Charging excessively for services or supplies 
• Misusing codes on a claim, such as upcoding or unbundling codes

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:

1. The member must inform Sanford Health Plan and/or their provider regarding all health insurance plans.
2. The member must cooperate with Sanford Health Plan by providing any information that is requested.

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:

• secondary to the plan covering the person as a dependent
• primary to the plan covering the person as other than a dependent

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: •

• The primary plan is the plan of the parent whose birthday is earlier in the year.
• If both parents have the same birthday, the plan that covered either of the parents longer is primary.

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: 

• If a court decree states that one of the parents is responsible for the child’s health care expense and the plan is aware of the decree, the plan of that parent is primary. This rule applies to claim determination periods or plan years commencing after the Plan is given notice of the court decree. 
• If a court decree states that both parents are responsible for the child’s health care expenses, health care coverage, or assigns joint custody without specifying responsibility, the rule for “Dependent Child Who Has Parents Living Together” will apply 68
• If there is no court decree allocating responsibility for the child’s health care expenses or coverage, the order is as follows: 
  • The plan of the custodial parent; o The plan of the spouse of the custodial parent; o The plan of the noncustodial parent; and then 
  • The plan of the spouse of the noncustodial parent.

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: 

• Primary, the benefits of a plan covering the person as an Employee, Member, or Retiree Subscriber (or as that person’s Dependent);
• Secondary, the benefits under the continuation coverage.

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: 

• Who is eligible for Medicare secondary benefits solely because of ESRD, and;
• During the Medicare coordination period of 30 months, which begins with the earlier of: i. the month in which a regular course of renal dialysis is initiated, or ii. in the case of an individual who receives a kidney transplant, the first month in which the individual became entitled to Medicare.

The Plan has secondary responsibility for the claims of a Member:

• Who is eligible for Medicare primary benefits solely because of ESRD, and;
• The Medicare coordination period of 30 months has expired

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.

• 100% of the fee schedule for the highest allowable procedures
• 50% of the fee schedule for the second highest allowable
• 50% of the fee schedule for any additional surgical procedures

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.

• Quality of Care (MM-GEN-030)

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:

• Services involving administration of anesthesia require the use of a valid five digit procedure code plus the appropriate modifier code.
• Providers are to bill the full charge amount for services. • Report elapsed time in minutes in item 24g on the CMS-1500 claim form.
• Convert hours to minutes and enter total minutes.

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:

• Providers must bill pre-laboring monitoring services with revenue code 072x – Labor Room/Delivery (excluding revenue code 0723 – circumcision).
• Providers must bill the following HCPCS code for these services:
  • S4005: Interim labor facility global (labor occurring but not resulting in delivery)
• Units must reflect the number of hours the patient was being monitored. 
• Pre-labor monitoring using revenue code 072x and HCPCS S4005 should not be submitted on the same claim as observation using G0378 as this reflects duplication of services.
• Additional nursing charges in the labor/ delivery room are not separately billable.
• Fetal monitoring and fetal stress or non- stress tests should be billed using revenue code 0732 with the appropriate CPT®/HCPCS code.

Additional claims criteria:

• Patient presents with early labor and is sent home and then subsequently delivers at a later date; appropriate to submit separate charges or payment for pre-labor monitoring services.
• Patient presents on multiple, distinct, encounters with early labor; each encounter should be submitted separately
• Patient delivers while being monitored for early labor; no separate outpatient charges or payment should be submitted and should subsequently be included in the inpatient delivery stay.
• Other ancillary services will continue to be billed separately on the same claim.
• Additional services submitted will be subject to APC logic when the provider is under an APC contract.

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:

• Wound Care
• State I and II pressure ulcers
• Incontinent care; bowel and bladder training
• Colostomy/Ilestomy care
• Foley catheter care (maintenance and irrigation); including teaching
• Insulin dependent diabetic care; including teaching
• Dressing changes
• Routine laboratory
• X-rays
• Pharmacy; (oral medications)
• Routine supplies
• Routine durable medical equipment (wheel chairs, walkers, canes, etc.)
• Respiratory therapy – 2 small volume nebulizers (Nursing Department)
• Low flow oxygen, 3 LPM or less
• Restorative therapy including ROM, functional maintenance

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: 

• Stage III and IV pressure ulcers
• Old tracheotomy care and supplies (2 or more suctionings per shift-3 shifts per day)
• NG, GI, G tube patient (enteral feeding pumps included)
• Simple IV therapy (hydration plus one medication is “simple”)
• Wound isolation not requiring a private room
• Respiratory therapy 3 or more small volume (Nursing Department)
• PT/OT/ST once a day (minimum 2 fifteen minute units) up to one hour of therapy per day, 5 days per week including therapy evaluation

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:

• Post-surgery care and monitoring every four hours
• Complex medical care*
• Complex IV management (multiple medications) NOTE: The costs of the IV medication is excluded from the per diem rate in excess of $35.00 PPD
• Rehabilitation (PT, OT, ST a combination of 1-3 hours per day BID)
• New tracheotomy; including teaching
  • *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: 

• Pulmonary/Respiratory 
• Cardiac/Circulatory
• Orthopedic 
• Gastrointestinal 
• Pancreas, liver, gall bladder and spleen disease
• Cancers and malignancies
• Kidney, urinary tract
• Wound/skin
• Endocrine and metabolic disease 
• Neurological/spinal 
• Infections
• Amputations
• Trauma

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:

• Durable Medical Equipment (DME) services. Providers will need to submit separate claims for these services;
• Ambulance services. Providers will need to submit separate claims for these services;
• Critical Access Hospitals;
• Indian Health Service Hospitals;
• Maryland hospitals under PPS waiver; 
• Hospitals in Guam, Saipan, America Samoa, and the Virgin Islands;
• Partial Hospitalization. Payment for outpatient mental health services are will be based on one of five H or S codes;
• Physician/professional services. Providers will need to submit separate claims for these services.

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:

• Instances where CMS requires an alternative code (ex. Observation, clinic, MRIs);
• CPT/HCPCS code on lines with Self- Administrable Drugs (Rev Code 637);Outpatient observation services and pay observation on a comprehensive APC basis;
• Packaging rules within CMS Outpatient Code Editor (OCE);
• Late charges – a corrected claim must be submitted if all services are not included on the original claim.

Sanford Health Plan deviates from CMS on the following guidelines: 

• Chemotherapy Medications: Imatinib, 100 mg, for both Imatinib and Gleevac will require HCPCS S0088 to be billed for appropriate payment. 
• Invalid Billing of Device Credit Logic: These condition codes, value amounts, and value codes will be accepted but not required. Payment will be adjusted, similar to Medicare’s pricing policy, when the condition codes, value amounts, and value codes are submitted on a claim.
  • Condition Codes 49 or 50
  • Value Amount on claims that include Value Code FD 
• Observation: The Plan will process and reimburse observation claims spanning greater than 72 hours as follows: 
  • The first 72 hours of observation will be billed on one UB-04 claim line with the admit date of service; 
  • Any additional hours over 72 will be billed on a separate UB-04 claim line with a different date of service than the admit date.
  • These two lines of observation, reflecting the entire stay, must be billed on the same UB-04 claim form. o For observation billing, the admit date of service is defined to be the date when observation services are initiated.
• Pre-labor Monitoring: Pre-labor monitoring services should be submitted according to SHP guidelines. Providers should submit revenue code 072x, excluding 0723 (circumcision) for pre-labor monitoring services using HCPCS S4005. The units should reflect the number of hours the patient was being monitored.
• Take Home Drugs/Supplies & Self- Administrable Drugs: The following revenue codes require valid HCPCS codes and should be submitted with the most specific code available.
  • 0253: Take Home Drugs
  • 0273: Take Home Supplies
  • 0637: Self-Administrable Drugs

  (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:

  • 0250: Pharmacy, General
  • 0259: Pharmacy, Other 
  • 0270: Medical/Surgical Supplies, General

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.

• Therapy services: These modifiers and G-codes will be accepted but not required.
  • Modifiers GN, GO, GP 
  • Non-payable therapy G-codes
  • Functional severity Modifiers (CH – CN)

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:

• CMS APC Weight File
• CMS Lab packaging(PSI Q4)
• CMS Lab paneling / multi-channeling logic
• Limit fee schedule payment to line item charge (i.e. Lab, DME, Therapies)
• Cost outliers pricing logic applied
  • Source for ratio of cost to charge (RCC) will be CMS value effective based on date quoted in provider contract. RCC will be held constant until the updating processing associated with the next provider contract year
  • Cost outlier payment percent to be comparable to CMS (ex. 50%) effective at the start of the contract year 
  • Source for payment factor (ex. 1.75) will be CMS value effective at the start of the contract year
  • Source for fixed threshold (ex. $3,250) will be CMS value effective at the start of the contract year

Sanford Health Plan will also apply the following guidelines:

• Claim level lesser of logic
• Provider specific conversion factors
• No wage adjustments
• Categories of covered codes with no specific pricing will default to specific % of charge stated in the contract (i.e. Inpatient Only Procedures PSI C, dialysis on TOB 13x/14x)
• Vaccines (PSI F and L): Pay based on code specific fee schedule amounts where available. If no fee schedule available, pricing will default to contract specific rate percent of billed charges
• CMS fee schedules for North Dakota, South Dakota, and Minnesota will be used based on where services were rendered

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:

• Validity edits
• Invalid age
• Invalid sex 
• Diagnosis/procedure and age or sex conflicts 
• Appropriate use of modifiers
• Volume/unit edits
• Revenue code that require HCPCS codes
• Conditions not payable under OPPS per CMS regulations
• National Correct Coding Initiative (CCI)
• Edits that implement payment policies
• Plan/DME exclusions
• Composite APCs

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: 

• Changes in technology 
• Changes in CPT codes
• Codes removed from Inpatient Only List
• New procedures or services
• Changes in resources used to perform services

Updates include: Quarterly updates to:

• New CMS codes
• OCE files including CMS CCI/MUE (Medically Unlikely Edits
• CMS Payment weights
• Packaging rules within CMS Outpatient Code Editor (OCE)

Annual updates to: 

• Payment adjustments
• Reweighting of conversion factor implemented based on the January CMS date 
• RCC factor based on latest RCC available for Optum through HCRIS 
• APC Grouper Version
• The Plan will apply updates for applicable APC groupings, new codes, and weights according to the final rule published by CMS quarterly.

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.

• May 1
• August 1
• November 1
• February 1

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.