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Sanford Health Plan

Sanford Health Plan

Prior Authorization

Pharmacy Information Sanford Health Plan Prior Authorization Member Rights - Sanford Health Plan

Prior authorization (certification or precertification) is the urgent or non-urgent authorization of a requested service prior to receiving the service. The approval for prior authorization is based on appropriateness of care and service and existence of coverage.

Points to remember

  • The member is ultimately responsible for obtaining prior authorization from the Utilization Management Department in order to receive in-network coverage. However, information provided by your office will also satisfy this requirement.
  • All requests for certification are to be made by the member or their practitioner’s office at least three (3) working days prior to the scheduled admission or requested service. In the event that health care services need to be provided within less than three (3) working days, contact the Utilization Management Department to request an expedited review.
  • All referrals to non-participating providers (at the recommendation of a participating provider) require prior authorization.

How to request Prior Authorization

Prior authorizations for health care services can be obtained by contacting the Utilization Management Department online, by phone or fax:

  • Online: Select “Submit/Request/Report” under “Provider Inquiries” on your secure mySanfordHealthPlan account at sanfordhealthplan.com/providerlogin. Click on “Submit a preauthorization/precertification.” Once you complete the required information click “Submit.” 
    NOTE: Oncology treatment and services must be authorized online at connect.eviti.com (effective 12/1/2016)
  • Phone: (800) 805-7938 and follow the appropriate menu prompts. Team members are available to take your calls from 8:00am to 5:00pm Central Standard Time, Monday through Friday. After hours you may leave a message on the confidential voice mail and someone will return your call the following business day.
  • Fax: Please fax the prior authorization form and supporting documentation to (605) 328-6813.

Services

Admission before the day of non-emergency surgery will not be covered unless the early admission is medically necessary and specifically approved by Sanford Health Plan. Coverage for hospital expenses prior to the day of surgery at an Out-of-Network facility will be denied unless authorized prior to being incurred.

The following services require prior authorization. New services added to the list are in red.

  • Airway Clearance Device (DME)
  • Ambulance Services for Non-Emergency Situations
  • Autonomic Testing
  • Back Surgery (effective 6/1/2016)
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Growth Stimulator – External (DME)
  • Botulin Toxin (Botox)
  • Brachytherapy
  • Breast Implant Removal, Revision, or Reimplantation when a non-Cancer diagnosis
  • Breast Reconstructive Surgery & Mastectomy
  • Breast Reduction Mammoplasty
  • Clinical Trials
  • Cochlear Implant (Device and Procedure)
  • Continuous Glucose Monitoring (CGM) System and Sensors for over age 18 from an Endocrinologist
  • Cranial Molding Helmet if not done by a Neurosurgeon
  • Deep Brain Stimulation
  • Dental Anesthesia for Children Under Age 5 Years (If Not Performed at a Sanford Health Facility)
  • Dental Anesthesia for Members with a Developmental Disability
  • Selected Durable Medical Equipment
  • Enteral / Parenteral Nutrition Therapy and Formula
  • Genetic Testing
  • Growth Hormone (Pharmacy)
  • Home Health Care Services
  • Home Infusion (IV) Therapy
  • Hospice Services
  • Hyperbaric Oxygen Therapy
  • Inpatient Hospital Admission: Medical, Surgical, obstetric (non-maternity), NICU, ICU, Rehabilitation, Mental Health/Chemical Dependency
  • Insulin Pump (DME)
  • Neuromuscular Electrical Stimulation
  • Oncology treatment and services (your provider must do online through eviti.com effective 12/1/2016)
  • Ossatron (ESWT)
  • Selected Orthotics (Including Repair, Replacement Parts, Supplies, & Maintenance)
  • Pain Control Program
  • Perception Sensory Threshold Test
  • Photodynamic Therapy (Cancer)
  • Phototherapy UBV Light Device (DME)
  • Prosthetic Limb (Including Repair, Replacement Parts, Supplies, & Maintenance)
  • Radio Frequency Ablation
  • Selected Outpatient Surgeries
  • Skilled Nursing Facility Services
  • Specialty Drugs & Selected Injectables*
  • Swing Bed Services
  • Sub-Acute Care Services
  • Spinal Cord Stimulator (Device and Implant Procedure)
  • Testosterone Injections
  • Transplant Services
  • Vagus Nerve Stimulation
  • Varicose Vein Treatment / Ablation:
    • Including but not limited to VNUS Closure, Endovenous Laser (EVL) and Sclerotherapy, are covered when medically indicated. These procedures do not require prior authorization when performed by a general surgeon, vascular specialist or interventional radiologist.
    • Other providers must provide proof of appropriate training and request prior authorization.
  • Vitamin B12 Injections

*Specialty Drugs and Selected Injectables: See the Sanford Health Plan Formulary for drug prior authorization requirements.

Additional services for Simplicity and TRUE members

The services listed above still apply to Simplicity and TRUE members. These plans offer pediatric dental coverage. Therefore, the following procedures require prior-authorization:

  • Medically-Necessary Dental Implants for Children Age 0-18 Years**
  • Medically-Necessary Orthodontics for Children Age 0-18 Years

**Other periodontic and endodontic procedures do not require prior authorization.

Prior authorization list for SEHCC members

The only addition to the SEHCC member listing is below; all of the above services still apply:

  • Positron Emission Tomography (PET) Scan

Prior authorization list for Heart of America members

For Heart of America commercial members, the list of services requiring prior authorization from pages 1 and 2 still applies. The one addition is:

  • Any services rendered by the Altru Health System need prior authorization because Altru providers and facilities are considered Out of Network.

For Heart of America Medicare Cost members, the list of services requiring prior authorization from pages 1 and 2 still applies. The one addition is:

  • Any services rendered by Trinity Health need prior authorization because Trinity Health providers and facilities are considered Out of Network.

Prior authorization list for Bethany Retirement Living members

The listing below is a complete listing for Bethany Retirement Living members.

  • Inpatient Hospitalizations at Out-of-Network Facilities (includes Out-of-Network inpatient non-emergency (planned) admissions for medical and/or surgical reasons; and non-emergency (planned) admissions for treatment of a mental health and/or substance use disorder);
  • Residential Treatment Facility admissions; and
  • Skilled Nursing Facility Admissions (In-and Out-of-Network);
  • Long Term Acute Care Facility Admissions (In-and Out-of-Network);
  • Transitional Care Unit Admissions (In-and Out-of-Network);
  • Home Health, Hospice, and Home IV therapy services (In-and Out-of-Network);
  • Infertility Services, including assisted reproductive technology for GIFT, ZIFT, ICSI and IVF (In-and Out-of-Network); and
  • Genetic Testing (In-and Out-of-Network).

Prior authorization list for NDPERS members

The following services require prior authorization for NDPERS members.

  • Inpatient hospital admissions (includes admissions for medical, surgical, obstetric, NICU, ICU, mental health and/or substance use disorders);
  • Selected outpatient procedures including but not limited to:
    • Covered Rhinoplasty surgeries for non-cosmetic reasons;
    • Obstructive Sleep Apnea Treatment, except for Continuous Positive Airway Pressure (CPAP);
    • Medically-Necessary Orthodontics;
  • Home Health, Hospice and Home IV therapy services;
  • Select Durable Medical Equipment (DME) including the below.
    • Prosthetic Limbs requiring replacement within 5 years;
    • Insulin infusion devices;
    • Insulin pumps;
    • Continuous Glucose Monitoring Systems (CGM);
    • Electric wheelchairs;
    • External hearing aids for the treatment of a hearing loss that is not due to the gradual deterioration that occurs with aging and/or other lifestyle factors.
  • Skilled nursing and sub-acute care;
  • Dental Anesthesia and associated Hospitalizations for all Members age 9 and older;
  • Back Surgery (effective 6/1/2016)
  • Chronic Pain Management;
  • Transplant Services;
  • Infertility Services, including assisted reproductive technology for GIFT, ZIFT, ICSI and IVF;
  • Genetic Testing;
  • Osseointegrated implants, including Cochlear implants and bone-anchored (hearing aid) implants;
  • Select Specialty Medications including:
    • Restricted Use Medications; and
    • Growth Hormone Therapy/Treatment;
  • Bariatric Surgery; and
  • Referrals to Non-Participating Providers, even if recommended by Participating Providers.
Note

Sanford Health Plan does not compensate practitioners and/or providers or other individuals conducting utilization review for issuing denials of coverage or service care. Any financial incentives offered to Utilization Management decision makers do not encourage decisions that result in underutilization and do not encourage denials of coverage or service.

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