Prior Authorization

Prior authorization is the urgent or non-urgent authorization of a requested service prior to receiving the service. The plan determines approval for prior authorization based on appropriateness of care, service, and existence of coverage. Please see below to learn more about the prior authorization process and what services require prior authorization.

During the prior authorization process, members and providers work together to get approval from Sanford Health Plan to provide coverage for specific procedures, medications or durable medical equipment. Sanford Health Plan's decision is based on a combination of medical necessity, medical appropriateness, and benefit limits. Prior authorization is never needed for emergency care. Covered services that need approval in advance are listed below.

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 the provider’s office will also satisfy this requirement.
  • All requests for authorization are to be made by the member or their provider’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 or facilities (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:
    • Members: Select “Ask a question” under “Contact Us” on your secure mySanfordHealthPlan account at sanfordhealthplan.com/memberlogin and click on the link for Utilization Management.
    • Providers: 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.”
  • Phone: Call the appropriate number below and follow the menu prompts.
    • NDPERS members (888) 315-0885 (M-F 8 a.m. to 5:30 p.m. CST)
    • North Dakota Medicaid Expansion members (855) 276-7214
    • Commercial, Self-funded or Sanford Group Health members (800) 805-7938
    • Team members are available from 8 a.m. to 5 p.m. 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: Providers: Fax the Medical Prior Authorization Request form and supporting documentation to:

What Services Require Prior Authorization

The following general listing includes services that require prior authorization. This list is subject to change based upon Sanford Health Plan Medical Management Policy updates, and the specifics for some plans may vary slightly from the listed or noted exceptions. Contact the Sanford Health Plan UM Department for additional information.

Please Note:

  • 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.

Service Prior Authorization Listing (as of 05/25/2017)

Procedure or Service Comments
Admissions

 Admission Include:

  • Inpatient Medical, Surgical, Behavioral Health or Chemical Dependeny
  • Inpatient Rehabilitation
  • Long Term Acute Care (LTAC)
  • Residential Treatment
  • Skilled Nursing Facility
  • Swing Bed
 Ambulance Services

 Includes the following:

  • Air Ambulance Services
  • Non-emergent transportation
 Clinical Trials  All clinical trials
 Durable Medical Equipment

Durable Medical Equipment (DME) includes but is not limited to:

  • Airway Clearance Device
  • Communication Device
  • Continuous Glucose Monitors and Sensors
  • Cranial Molding Helmet
  • Dental Appliances
  • Home INR Monitor
  • Hospital or Specialty Beds
  • Insulin Pump
  • Selected Orthotics
  • Phototherapy UVB Light Device
  • Pneumatic Compression with external pump
  • Power Wheelchair and Scooter
  • Prosthetic Limb

 Home Health / Hospice Services

 Home Health and Hospice Services include:

  • Home Health Services
  • Home Infusion (IV) Services
  • Hospice Services
 Implants / Stimulators

Implants and Stimulators include:

  • Bone Growth (external)
  • Cochlear Implant (Device and Procedure)
  • Deep Brain Stimulation
  • Gastric Stimulator
  • Spinal Cord Stimulator (Device and Procedure)
  • Vagus Nerve Stimulator
 Oncology Services and Treatment  Includes all chemotherapy and radiation therapy as part of an oncology treatment plan
 Outpatient Services

Outpatient Services include but is not limited to:

  • Alopecia treatment
  • Applied Behavioral Analysis (ABA)
  • Biofeedback
  • Botox
  • Brachytherapy
  • Chelation Therapy
  • Dental Anesthesia
  • Genetic Testing
  • Home Sleep Study
  • Hyperbaric Oxygen Therapy
  • Infertility Treatment
  • Medical Nutrition
  • Neuromuscular Electrical Stimulation
  • Orthodontia
  • Photodynamic Therapy
  • Platelet Rich Plasma (PRP)
  • Radiofrequency Ablation
  • Varicose Vein Treatment
 Outpatient Surgery

Outpatient Surgery includes but is not limited to:

  • Abdominoplasty or Panniculectomy
  • Bariatric Surgery
  • Blepharoplasty
  • Breast Implant Removal, Revision or Re-implantation
  • Breast Reconstructive and Mastectomy
  • Endoscopic Sinus Surgery
  • Intrathecal Pain Pump
  • Mammoplasty
  • Orthognatic Procedures
  • Rhinoplasty
  • Septoplasty
  • Spine Surgery
  • Temporomandibular Joint (TMJ)
 Spine surgery  All inpatient and outpatient spine surgery
 Transplants  Includes transplant evaluation and all transplant services including artificial pancreas

Additional Services for 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

For complete prior authorization information, please refer to the member plan document.

*Please note: Refer to the SHP pharmacy handbook and formulary for medications requiring prior authorization.