Members, providers with knowledge of a member’s condition or an authorized representative have the right to file a complaint or appeal of any adverse determination made by Sanford Health Plan.
An oral complaint can be submitted by calling Customer Service.
Written complaints can be submitted by mail or fax by accessing the Appeals and Denials Complaint Form found in Provider Resources.
Providers may request an urgent (or expedited) appeal on behalf of the member without the member’s signature (except for ND Medicaid Expansion members). To determine when an appeal may be considered urgent, please see the Plan’s definition above.
A pre-service appeal may be requested for covered services as described above if an authorization request is denied in whole or in part. Determinations will be made within 30 days (14 days for Medicaid Expansion Members) unless additional information is required; in these cases a time extension may occur. The member, their authorized representative and the provider will be sent a determination letter after the review has occurred.
A post-service appeal may be requested as described above if a service has already occurred. After an appeal is received, a determination will be sent via mail within 30-60 days to the member, their representative and the provider involved in the appeal to inform them of the plans decision. Members have the following deadlines to file an appeal:
For more information or questions about the complaint or appeals process visit the Provider Portal to view the full policy or contact the Appeals and Denials Department at (877) 652-8544.
The Plan is committed to treating members in a manner that respects their rights. In this regard, the Plan recognizes that each member (or the member’s parent, legal guardian or other representative if the member is a minor or incompetent) has the right to the following:
In accordance with the Minnesota Department of Health, and the National Committee for Quality Assurance (NCQA), you have certain rights as member of Sanford Health Plan of Minnesota, including the following: 82
ENROLLEE BILL OF RIGHTS (Minnesota Only)
Each Member (or the Member’s parent, legal guardian or other representative if the Member is a minor or incapacitated) is responsible for cooperating with those providing Health Care Services to the Member, and shall have the following responsibilities: