Credentialing and the Sanford Provider Hub - Sanford Health Plan
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Provider Fast Facts
March 2021 | An eNewsletter from Sanford Health Plan
Credentialing and the Sanford Provider Hub
In 2021, Sanford Health is moving credentialing to a secure, cloud-based software solution.
This new Sanford Provider Hub will provide:
• A user-friendly, automated experience
• Streamlined processes
• A reduction in paperwork
We’re excited to bring the Sanford Provider Hub to you
in April 2021! Watch for further details via email and U.S. mail soon.
1
Policies Update
Below, you’ll find the latest policy updates—additions,
deletions, edits—for your reference. Please call us
at (800) 601-5086 Option 2, Option 4 for Provider
Relations if you have any questions.
New Benefit Reimbursement Policies:
• Dental Services
• Oral and Maxillofacial Surgery
• Reconstructive Surgery
Upcoming Policies:
• O
utpatient Services Prior to Inpatient Admission
effective 4/1/21
• Increased Procedural Services (Modifier 22)
effective 4/1/21
• Benefit Reimbursement Policy effective 4/1/21
• Consultation Services Benefit Reimbursement
effective 4/1/21
Optum CES Edits
Sanford Health Plan continues to implement additional claims edits. Check periodically for
details of future edits to be released. A document detailing the claim edits is available to
you here on the PROVIDER RESOURCES PAGE. The resource will be updated as Sanford
Health Plan implements new edits.
2
Helping Your Patients Get Screened for Colorectal Cancer
Many times your patients rely on your professional recommendation and the discussions you have with them
on their options will help them schedule their screening for colorectal cancer. By letting your patients know
what to expect — including what their responsibility is for each type of screening, you can help make their
preparation process much more manageable and less intimidating.
Most insurance plans classify colorectal cancer screening as a preventive health care service and, therefore,
cover the cost of the screening. With that being said, your patients should know that preventive services like
screening tests may sometimes result in a follow-up diagnostic procedure, especially if a polyp is found and
biopsied. Once a preventive services like colorectal cancer screening becomes diagnostic, this may change
a patient’s coverage. The patient may then be required to pay an out-of-pocket expense (co-pay, deductible,
coinsurance).
A deductible may need to be paid if the colonoscopy is prescribed to diagnose an unknown health problem the
patient is experiencing, such symptoms as bleeding or irregularity. In this circumstance, the procedure would
be considered diagnostic.
Discussing these key points with your patients during their exams is one way to help ease their nerves and
help increase your screening rates. If your patients have questions regarding their benefits, they can call
the Customer Service number found on their Sanford Health Plan ID card or log into mySanfordHealthPlan
member portal.
For more information regarding screening guidelines, please log onto the Sanford Health Plan website and
review the Clinical Practice Guidelines.
At Home Testing Update
At-home testing kits such as Fit or Cologuard that produce an adverse result indicates a
colonoscopy is needed. Currently, with an adverse result the colonoscopy would not be treated as
a screening, but instead as diagnostic and would be subject to copay, deductible or coinsurance.
Effective 4/1/21, Sanford Health Plan will allow colonoscopies to be covered at 100% when done after an at-home screening
with an adverse result.
Preventative Screening Diagnostic Testing
A test (eg, colonoscopy, FIT, stool DNA test, or FOBT) A colonoscopy to diagnose a health condition in response
performed on a patient who does not have symptoms to symptoms, such as:
but who is in a group at risk for colorectal cancer, such • Bleeding or irregularity
as those: • Positive results of a preventive screening
• Between the ages of 50 and 75 with a family history of
The patient may have to pay a co-pay, coinsurance,
colorectal cancer
or deductible.
• With few exceptions, health care plans cover
screenings with no out-of-pocket cost to the patient.
Example A: For a patient’s 50th birthday, he chooses to Example A: The FOBT has a positive result; his doctor
have a simple FOBT. recommends a colonoscopy to determine the cause
of the bleeding. The colonoscopy may be considered
diagnostic since it will be used to determine why the
patient has blood in his stool.
Example B: A patient’s mother had colorectal cancer, so Example B: During the preventive screening
she opts for a colonoscopy. colonoscopy, polyps are found, removed, and sent to
a lab for testing. The testing itself may be considered
diagnostic since the lab results will need to be reviewed
to determine if the polyp is cancerous.
3Changes Coming for Prior Authorizations
Participating providers will be responsible for not approving the request. Additionally, the
obtaining authorizations starting in 2021. If a member may also appeal if they feel they are
provider is non-participating, the member will be being held responsible when not appropriate,
responsible for obtaining the prior authorization. and documentation must be submitted to prove
In the event that an authorization is not obtained, whether the member consented to proceed with the
and a retrospective authorization is requested procedure. For further questions regarding these
and deemed not medically necessary after review, changes, please see our FAQ document HERE or
the provider will be responsible for the charges, call Provider Relations at (800) 601-5086.
resulting in provider write off. Some exceptions
will be made on a case by case scenario. For Q: W
ill the entire claim deny to Provider
example, if a provider submits a prior authorization Responsibility if no Authorization is in place?
that results in a denied request and the member A: No, the denial will continue to be at the line
chooses to still have the procedure done, it will be item level
considered member responsibility. In this event, Q: W
hat is the time period given to submit a
the provider should bill with a GA or GY modifier retroactive authorization?
so that the responsibility is on the member. If the
A: As of 1/1/21 the time period for retroactive
modifier is not used, the provider may submit a
authorizations to be accepted has been shortened
reconsideration for review. The provider must
from 180 days to 60 days.
submit documentation that proves to member
agreed to proceed with the care despite insurance
Electronic Prior Authorization
To better serve our members and providers, we will require electronic prior authorization
submission effective Oct. 1, 2020. Providers currently not using the electronic submission option
will need to submit referrals electronically. Sanford Employees and internal users: Please see the
training resource HERE , or sign up for additional classes in the Sanford Success Center.
EXTERNAL PROVIDERS: Please submit authorization requests via Provider Portal HERE. For
questions, please contact Provider Relations at (800) 601-5086.
Covid Vaccine Administration Allowed Amount
Sanford Health Plan has established the following allowed amounts for administration of the Covid vaccine.
Please note this is for administration only. We will continue monitoring vaccine developments and will add
administration allowed amounts for vaccines produced by other manufacturers when they become available.
Code Description Allowed Amount
0001A Pfizer 1st dose $28.81
0002A Pfizer 2nd dose $48.29
0011A Moderna 1st dose $28.81
0012A Moderna 2nd dose $48.29
0021A AstraZeneca 1st dose $28.81
0022A AstraZeneca 2nd dose $48.29
0031A Janseen* (1 shot dose) $48.29 *Janseen is a division of Johnson & Johnson
4Utilization Management: Phone Prompts
Innovating to Improve Access Have Recently
to Medically Necessary Care
Changed
PA REQUIREMENTS FOR ADVANCED IMAGERY
To provide you with you
Sanford honors its commitment to you, our providers, and most certainly
our patients / members by continuing to look for ways to optimize efficiencies the best experience we
across our enterprise operations. As a part of these ongoing efforts, we have updated our phone
are working to modernize our Utilization Management (UM) capabilities by systems and with this
enhancing Prior Authorization (PA) processes to alleviate administrative and change there may be
provider burden while improving the overall patient experience and access
to high quality care.
some differences. You
will still use the numbers
Last month we provided detail on one of Sanford Health Plan initiatives
which will expand the authorization process to include advanced imaging at the end of this
through our partnership with eviCore Healthcare. Based on evidence-based publication to reach the
clinical guidelines, this effort will enable the organization to confidently appropriate departments.
provide the highest quality, appropriate care to our patients. Beginning
Prior to arriving at the
Dec. 14th, 2020, select Sanford Health members will require prior
authorization from eviCore for dates of service Jan. 1, 2021 and thereafter. appropriate department,
Services performed without authorization may not be reimbursed. you will be prompted
Standardization and automation of PA processes will offer additional to enter if you are a
support and efficiency across key UM functions and will enable member, provider or
improved outcomes and an enhanced patient experience by providing have sales inquiry. Once
the right care, with the right provider, and in the right setting. Stay
within the provider
tuned for more information and updates on our progress regarding
these exciting enhancements, and to learn more about Sanford’s efforts menu your call will be
to deliver greater value to you and the communities we serve. routed to the team that
To learn more about this new requirement please check out the will most efficiently be
dedicated website for Providers HERE. On the dedicated website able to answer your
you will be able to: questions. We thank you
1. Register for training (in General Resources Tab, Registration Instructions) for your patience as we
2. Register for sign in (in General Resources Tab, Registration Instructions) embark on some amazing
3. Review CPT code list for services that require authorization technology to create
(in Solution Resources Tab, Radiology icon) the best experience
4. Access Evidence Based Clinical Guidelines for you as a provider
For questions on how to get started please call: eviCore’s call and our members.
center is open from 7 a.m. to 7 p.m. CST (844) 635-7225.
COVID-19: Updated Coverage Announcement
Stay up-to-date on all COVID-19 information and find resources specifically
for providers by visiting this webpage.
Have additional COVID-19 questions? Submit your questions HERE.
5Contact Us:
CONTACT FOR: Member eligibility & benefits, member claim status,
provider directory, complaints, appeals, report member discrepancy
information
memberservices@sanfordhealth.org
Customer Service
Monday-Friday, 8 a.m. to 5 p.m. CST | 800) 752-5863
NDPERS Customer Service
Monday-Friday, 8 a.m. to 5:30 p.m. CST | (800) 499-3416
ND Medicaid Expansion
Monday-Friday, 8 a.m. to 5 p.m. CST | (855) 305-5060
CONTACT FOR: Preauthorization/precertification of prescriptions
or formulary questions
pharmacyservices@sanfordhealth.org
Pharmacy (855) 305-5062
NDPERS Pharmacy (877) 658-9194
ND Medicaid Expansion (800) 755-2604 | TTY: 711
CONTACT FOR: Preauthorization/precertification for medical services
um@sanfordhealth.org
Utilization Management (800) 805-7938
NDPERS Utilization Management (888) 315-0885
ND Medicaid Expansion (855) 276-7214
CONTACT FOR: Assistance with fee schedule inquiries, check
adjustments & reconciling a negative balance, request explanation of
payment (EOP), claim reconsideration requests, W-9 form, change/
updating information, provider education
providerrelations@sanfordhealth.org
Provider Relations (800) 601-5086
CONTACT FOR: Requests to join the network and contract-related
questions and fee schedule negotiation
sanfordhealthplanprovidercontracting@sanfordhealth.org
Provider Contracting (855) 263-3544
Hearing or speech impaired TTY | TDD (877) 652-1844
Translation Assistance for Non-English Speaking Members (800) 892-0675
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