Section 7: Members

7.1 Problem Resolution

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.

  • The Member has the right to participate in decisions and express preferences regarding his or her health care, including traditional, alternative, and non-treatment options and each option’s associated risks, benefits, alternatives and consequences, if applicable.
  • If the Member’s plan based in Minnesota, providers are not required to obtain the member’s signature to file an appeal or complaint.
  • For ND Medicaid Expansion, the member’s signature is required.
    • Appeals by a Member, an Authorized Representative of the Member (as designated in writing by the Member) or Provider and/or Practitioner (with written consent from the Member) must be made within sixty (60) calendar days from the date printed on the notification of an Adverse Benefit Determination.
    • Requests for a State Fair Hearing, through the State of ND Department of Human Services, must be made within 120 days of the appeal determination made by Sanford Health Plan. Note that Non-Covered Service Determinations are not eligible for State Fair Hearings.
    • Grievances (complaints) may be filed orally or in writing by the Member, an Authorized Representative of the Member 80 (as designated in writing by the Member) or Provider and/or Practitioner (with written consent from the Member) at any time with Sanford Health Plan. 
    • Help is available to assist with any of these processes by contacting Customer Service at (855) 305-5060. If a Member wishes the services being appealed to continue during an appeal, the appeal must occur within 10 calendar days of receiving the notice of Adverse Benefit Determination. The Member may be required to pay for the disputed services provided while the appeal decision is pending if the final decision is determined to be unfavorable. 
  • For all other plans, the provider may only file an appeal or complaint on the member’s behalf without the member’s signature if the situation is considered urgent (waiting the routine processing time may seriously jeopardize the member’s life or health, ability to regain maximum function or subject them to severe pain that cannot be managed without the service or treatment).

7.1.1 Oral and Written Complaints

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.

7.2 Appeals

7.2.1 Expedited Appeal

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.

7.2.2 Prospective Appeal

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.

7.2.3 Retrospective Appeal

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:

  • 60 days for ND Medicaid Expansion members
  • 180 days for most plans
  • No deadline for Minnesota Members

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.

7.3 Member Rights

7.3.1 South Dakota, Iowa, Minnesota and North Dakota Member Rights:

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:

  1. Members have the right to receive impartial access to treatment and/or accommodations that are available or medically indicated, regardless of race; ethnicity; gender; gender identity; sexual orientation; medical condition, including current or past history of a mental health and substance use disorder; disability; religious beliefs; national origin; age; or sources of payment for care, in accordance with access and quality standards.
  2. Members have the right to considerate, respectful treatment at all times and under all circumstances with recognition of their personal dignity. 
  3. Members have the right to be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy.
  4. Members have the right to request and receive a copy of medical records used by the plan during a coverage determination from their originating provider and to request any amendments or corrections. No copies will be forwarded from the health plan (NDME Only).
  5. Members have the right, but are not required, to select a Primary Care Physician (PCP) of their choice. If a member is dissatisfied for any reason with the PCP initially chosen, he/she has the right to choose another PCP.
  6. Members have the right to expect communications and other records pertaining to their care, including the source of payment for treatment, to be treated as confidential in accordance with the guidelines established in applicable Federal and State laws.
  7. Members have the right to know the identity and professional status of individuals providing service to them and to know which physician or other practitioner is primarily responsible for their individual care. Members also have the right to receive information about our clinical guidelines and protocols. 
  8. Members have the right to a candid discussion with the practitioner(s) and/or Provider(s) responsible for coordinating appropriate or medically necessary treatment options for their conditions in a way that is understandable, regardless of cost or benefit coverage for those treatment options. Members also have the right to participate with practitioners and/or Providers in decision-making regarding their treatment plan.
  9. Members have the right to give informed consent before the start of any procedure or treatment.
  10. When Members do not speak or understand the predominant language of the community, the Plan will make its best efforts to access an interpreter. The Plan has the responsibility to make reasonable efforts to access a treatment clinician that is able to communicate with the Member.
  11. Members have the right to receive printed materials that describe important information about the Plan in a format that is easy to understand and read.
  12. Members have the right to a clear grievance and appeal process for complaints and comments and to have their issues resolved in a timely manner.
  13. Members have the right to appeal any decision regarding medical necessity made by the Plan and its Providers.
  14. Members have the right to terminate coverage under the Plan, in accordance with applicable Employer and/or Plan guidelines.
  15. Members have the right to receive information about the organization, its services, its Providers and Members’ rights and responsibilities, in accordance to 42 CFR §438.10 (NDME Only).
  16. Members have the right to make recommendations regarding the organization’s Member’s rights and responsibilities policies.
  17. Members have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, or the use of restraints and seclusion (NDME Only).
  18. North Dakota Medicaid Expansion Members have the right to be free to exercise all rights and that by exercising those rights; they shall not be adversely treated by the State, the Plan, and/or its participating Providers.

7.3.2 Minnesota Member Rights:

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

  1. COVERED SERVICES. These are network services provided by participating Sanford Health Plan network providers or authorized by those providers. Your Policy fully defines what services are covered and described procedures you must follow to obtain coverage.
  2. PROVIDERS. Enrolling with Sanford Health Plan does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the Sanford Health Plan network, you must choose amount from remaining Sanford Health Plan network providers.
  3. EMERGENCY SERVICES. Emergency services from providers outside the Sanford Health Plan network will be covered only if proper procedures are followed. Read this Policy for the procedure, benefits and limitations associated with emergency care from Sanford Health Plan network and non-Sanford Health Plan network providers.
  4. EXCLUSIONS. Certain service or medical supplies are not covered. Read this Policy for a detailed explanation of all exclusions.
  5. CANCELLATION. Your coverage may be canceled by you or Sanford Health Plan only under certain conditions. Read your Policy for the reasons for cancellation of coverage.
  6. NEWBORN COVERAGE. A newborn infant is covered from birth. Sanford Health Plan will not automatically know of the newborn’s birth or that you would like coverage under this Plan. You should notify Sanford Health Plan of the newborn’s birth and that you would like coverage. If your Policy requires an additional payment for each dependent, Sanford Heath Plan is entitled to all enrollment payments due from the time of the infant’s birth until the time you notify the Plan of the birth. Sanford Health Plan may withhold payment of any health benefits for the newborn infant until any enrollment payment you owe is paid.
  7. PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with Sanford Health Plan does neither guarantees that any particular prescription drug will be available nor that any particular piece of medical equipment will be available, even if the drug or equipment is available at the start of the Policy year.

ENROLLEE BILL OF RIGHTS (Minnesota Only)

  1. Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice.
  2. Enrollees have the right to refuse treatment, and the right to privacy of medical and financial records maintained by the health maintenance organization and its health care providers, in accordance with existing law. 
  3. Enrollees have the right to file a complaint with the health maintenance organization and the commissioner of health and the right to initiate a legal proceeding when experiencing a problem with the health maintenance organization or its health care providers.
  4. Enrollees have the right to a grace period of 31 days for the payment of each premium for an individual health maintenance contract falling due after the first premium during which period the contract shall continue in force. 
  5. Medicare enrollees have the right to voluntarily disenroll from the health maintenance organization and the right not to be requested or encouraged to disenroll except in circumstances specified in federal law.
  6. Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by the health maintenance organization.

7.4 Member Responsibilities for Minnesota, North Dakota, Iowa, and South Dakota

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: 

  1. Members have the responsibility to provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health. They have the responsibility to report unexpected changes in their condition to the responsible practitioner. Members are responsible for verbalizing whether they clearly comprehend a contemplated course of action and what is expected of them.
  2. Members are responsible for carrying their Plan ID cards with them, and for having member identification numbers available when telephoning or contacting the Plan, or when seeking health care services. Members are responsible for following all access and availability procedures.
  3. Members are responsible for seeking emergency care at a Plan participating emergency facility whenever possible. In the event an ambulance is used, Members are encouraged to direct the ambulance to the nearest participating emergency facility unless the condition is so severe that you must use the nearest emergency facility. State law in North Dakota, Iowa, and South Dakota requires that the ambulance transport you to the hospital of your choice unless that transport puts you at serious risk. 
  4. Members are responsible for notifying the Plan of an emergency admission as soon as reasonably possible and no later than forty- eight (48) hours (ten (10) days for North Dakota Medicaid Expansion members) after becoming physically or mentally able to give notice.
  5. Members are responsible for keeping appointments and, when they are unable to do so for any reason, for notifying the responsible practitioner or the hospital.
  6. Members are responsible for following their treatment plan as recommended by the Provider primarily responsible for their care. Members are also responsible for participating in developing mutually agreed-upon treatment goals, and to the degree possible, for understanding their health care conditions, including mental health and/or substance use disorders.
  7. Members are responsible for their actions if they refuse treatment or do not follow the Practitioner’s instructions.
  8. Commercial Members are responsible for notifying the Plan through their employer within thirty (30) days if they change their name, address, or telephone number. Medicaid Expansion Members are responsible for notifying the North Dakota Department of Human Services Division of Medical Services within ten (10) days at toll-free at (844) 854-4825 | ND Relay TTY: (800) 366-6888 (toll-free) if they change their name, address, or telephone number. NDPERS Members are responsible for notifying NDPERS within thirty- one (31) days if they change their name, address, or telephone number.
  9. Commercial Members are responsible for notifying their employer and/or the Plan of any changes of eligibility that may affect their membership or access to services. The employer is responsible for notifying the Plan. North Dakota Medicaid Expansion Members are responsible for notifying the North Dakota Department of Human Services Division of Medical Services of any changes of eligibility that may affect their membership or access to services. NDPERS Members are responsible for notifying their employer of any changes of eligibility that may affect their membership or access to services. NDPERS is responsible for notifying the Plan.