Medicare Members Provider Directory

As Dakota Retiree Plan members, you can utilize Medicare participating providers just as you have with your previous carrier.

Member Messenger Newsletter

Are you receiving the Sanford Health Plan newsletter, Member Messenger? This newsletter is produced quarterly and contains information you need on health, wellness, medical and pharmacy coverage and answers to commonly asked questions.

You can always find the latest version in your secure mySanfordHealthPlan account. Log on at sanfordhealthplan.com/memberlogin. If you do not have an account, use your medical ID card and click Create an Account. The Member Messenger newsletter is found under the Education tab.  

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Member Messenger Newsletter

Amendment to Your Certificate of Insurance

Sanford Health Plan recently mailed certificate of insurance amendments for the following plans:

  • Grandfathered Dakota PPO/Basic Plan
  • Non-Grandfathered Dakota PPO/Basic Plan
  • Non-Grandfathered Dakota High Deductible Health Plan

The amendment that you received had an incorrect reference to custom made orthotics under the durable medical equipment benefit; and indicated they were “not” covered instead of “now” covered.

The document has been corrected to “now” covered and can be found here. We apologize for the error. If you have questions about your benefits, please contact our Customer Service Department at (800) 499-3416.

Amendement to Certificate

Non-Medicare Members FAQ

9) Will I see any changes to my out-of-pocket expenses when NDPERS changes to Sanford Health Plan?
Maybe. Because hospital and clinic contracts are unique to Health Plans and custom for each provider, you may see differences in your cost sharing amount, such as the amount that goes towards your co-insurance. Sometimes  your co-insurance amount may be less for services than in prior years, and sometime you may pay a little more. However, your plan of benefits or coverage (deductible, copayments, and coinsurance) did not change with the move to Sanford Health Plan. For example, your prescription copay, coinsurance %, and $1,000 coinsurance maximum will still be the same. Since a Health Plan’s contracts with its providers are confidential and proprietary, it is not possible for Sanford Health Plan to duplicate the prior insurance company reimbursements for each specific service.  

10) Will Sanford Health Plan give me credit for the out of pocket costs that I have incurred so far this year?
Yes. Sanford Health Plan will be receiving periodic files from your previous carrier, showing the amount of out of pocket costs you incurred from January 1, 2015 – June 30, 2015.  This includes your deductible and coinsurance amounts.  At the same time, we will be processing claims incurred on or after July 1, 2015.
You may experience claim adjustments or processing delays as your cost sharing amounts are updated with Sanford Health Plan. These adjustments will be indicated on your Explanation of Benefits (EOB) with a description of “Claim adjusted due to updated accumulations from previous carrier”.

11) Is anything changing with my prescription drug coverage?
The drug benefit design will remain the same and you can continue to use your current pharmacy.

12) I filled my regular monthly prescription using my new Sanford Health Plan ID card.  Why did I pay a different amount than my last fill?
Because pharmacies have unique and custom contracts, you may experience a different cost sharing amount for your pharmacy coinsurance amount.  Some members may have lower costs and others may experience higher costs. However, your benefits and coverage did not change, for example, your prescriptions copay, coinsurance %, and $1,000 coinsurance maximum will remain the same. If you have a question about your medication, please contact our Pharmacy Department at (888) 315-0885.

13) Will I still have the $200 annual allowance for preventive screening services after July 1, 2015?
Yes. The plan was bid based on your current plan design; therefore, this benefit will continue to be available to NDPERS health plan members.

14) Does Sanford Health Plan require preauthorization? What is the preapproval process?
Prior to accessing certain services and higher levels of care, Sanford Health Plan has a process in place for advance notification (preauthorization/prior approval). Click here to view the full listing of these services.

15) What if I have primary and secondary insurance coverage from 2 different insurance carriers?
If Sanford Health Plan is the primary payer, your claims will be submitted to the secondary payer following payment.  If Sanford Health Plan is not your primary payer, you may want to check with your other carrier or your provider.  Your provider may submit the claim and payment information to the second payer, or you may have to submit your primary payer Explanation of Benefits (EOB) along with the itemized statement of services, to the secondary payer.

16) What if I have primary and secondary prescription drug coverage from 2 different insurance carriers?
If both coverages are with Sanford Health Plan, then Express Scripts, Inc. will automatically coordinate at the pharmacy for you. 
If Sanford Health Plan is your primary payer and your secondary coverage is not with Sanford Health Plan, you may want to check with your pharmacy.  Your pharmacy may submit the claim and payment information to the secondary payer for you, or you may have to submit the itemized statement for your prescriptions from Sanford Health Plan to your secondary payer.

If Sanford Health Plan is your secondary coverage, you may want to check with your pharmacy.  Your pharmacy may submit the claim and payment information to Sanford Health Plan for you, or you may have to submit the itemized statement for your prescriptions from your primary payer to Sanford Health Plan for processing.

17) What if Sanford Health Plan is both my primary and secondary insurance coverage?
If Sanford Health Plan is the primary payer, your claims will be processed and an Explanation of Payment (EOP) will be sent to the provider to let them know what is paid from your primary insurance.  If Sanford Health Plan is also the secondary insurance, it is the provider’s responsibility to submit the claim to your primary carrier and once that is paid to then resubmit the claim to Sanford Health Plan for processing of the secondary insurance.  It is important to inform your provider if you have primary and secondary insurance.

1) How does my provider network work with Sanford Health Plan?
Sanford Health Plan is offering you the same PPO network you had with your previous carrier. In addition, when you are traveling or accessing care outside the service area, you will have access to our nationwide network. Click here to view your provider directory.

2) What if I don’t see my provider in the directory?
If you don’t see your provider in our directory, you can nominate your provider to be in our network by submitting a Provider Nomination Form.

3) Is Mayo in the network?
Yes. You can access Mayo for services and coverage will remain at the Basic level.

4)  Is Essentia Health in the network?
Yes. However, providers must complete Sanford Health Plan's credentialing terms and conditions before appearing in the Provider Network Directory. Claims continue to be processed in-network during the credentialing process.

5) Is Trinity Health in the network?
Yes. However, providers must complete Sanford Health Plan's credentialing terms and conditions before appearing in the Provider Network Directory. Claims continue to be processed in-network during the credentialing process.

6) What is the provider credentialing process with Sanford Health Plan?
Sanford Health Plan follows a special credentialing process with providers in its network because it holds a National Committee for Quality Assurance (NCQA) Accreditation. This accreditation is awarded to health plans who have demonstrated diligence in their focus on quality care and continuous quality improvement initiatives.

7) Do I need a referral to see an in-network specialty physician?
No.

8) Does Sanford Health Plan utilize participation contracts whereby physicians in network agree to a full fee schedule?
All of Sanford Health Plan’s provider contracts include a provision that the covering Practitioner must agree that he or she will accept the compensation from the Plan pursuant to the negotiated fee schedule as payment in full for any services rendered to Members and specifically precludes the provider from "balance billing" the member any difference between the billed charges and the health plan's allowed amount.

18) I already have an appointment or covered procedure scheduled after July 1, 2015. Is there anything I need to do?

If the provider or facility is already in the Sanford Health Plan network, no further action is required by you. We will honor any authorizations, treatment programs or referrals that were approved by the previous insurance company.

If you don’t see your provider in our directory, you can nominate your provider to be in our network by submitting a Provider Nomination Form.

19) What is the process in selecting the carrier for the health insurance plan?
The group health insurance plan, as well as all NDPERS group insurance products, are required to follow a bid process as provided in NDCC 54-52.1. The NDCC gives the authority to the NDPERS board to select a carrier to provide the services of the plan.

20) Can you describe the transition of care process for members?
Sanford Health Plan will obtain previous preauthorization forms from BCBSND prior to the transition. Sanford Health Plan has committed to honoring services and treatment plans for NDPERS members that received prior approval and preauthorization from BCBSND prior to July 1, 2015.

21) How can BCBSND share data with Sanford Health Plan, such as prior-authorization requests?
Under federal HIPAA privacy laws, “covered entities” such as a health insurance company, is permitted to use and disclose protected health information (PHI), without an individual’s authorization, for treatment, payment, and health care operations. These activities include determining eligibility or coverage, utilization review activities and claims management activities. Such information is always sent in a secured file format.

22) Is the upcoming change in how NDPERS administers the Retiree Health Insurance Credit (RHIC) due to the change of insurance carrier to Sanford Health Plan?
No, the change is not related to the carrier change. For information about the RHIC, please refer to http://www.nd.gov/ndpers/health-credit/retiree-health-credit-portability.html or contact NDPERS at (800) 803-7377 or (701) 328-3900.

23) I received a termination letter from BCBSND, what does this mean?
Although this letter indicated your coverage has been terminated, please understand the coverage is simply being transitioned from your current carrier to Sanford Health Plan effective July 1, 2015. All those that are currently eligible and enrolled in health insurance coverage through NDPERS will continue to be covered with a seamless transition to Sanford Health Plan. As a member, you will be receiving your new ID cards and welcome packet which explain this transition in further detail.

24) Who is Optum and why are they calling me?
Optum is a third party vendor that Sanford Health Plan hired to investigate possible third party liability claims. If you have medical services that appear to be from an injury or accident, Optum will contact you by phone or letter to investigate. If you did have an injury or an accident, and it was caused by another party, that third party may responsible for payment of your treatment.  This is called Subrogation.

If your treatment was not related to an accident or injury, it is important to let Optum know as soon as possible. If you receive a letter or a phone call from Optum, please respond in a timely manner so that your claims can be processed without further delay. If you do not respond to Optum’s inquiries, your claims will be denied.

25) What impact does the Supreme Court decision on same-sex marriage have on NDPERS Plan?
On June 26, 2015, the Supreme Court of the United States recognized that all couples have a fundamental right to marriage, regardless of their gender. In addition, each state must recognize a marriage that was entered into in a different jurisdiction, or state. In accordance with this court decision, NDPERS will make changes to your Certificate of Insurance and the eligibility requirements for spouses. You will receive a copy of the amendment in the mail. You must contact NDPERS to add your spouse and/or their children to your NDPERS Plan within the following timeframes:

  • 1. Same-sex marriages that occurred prior to June 26, 2015: NDPERS will have a special enrollment period from July 1, 2015 through September 30, 2015. Coverage will be effective retroactive to July 1, 2015. If the Subscriber does not enroll during this eligibility period, the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period with coverage effective the following January 1st.
  • 2. Same-sex marriages that occur on or after June 26, 2015: The Subscriber must submit an application for coverage to NDPERS within the first thirty-one (31) days of the event. If the Subscriber does not enroll when initially eligible, the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period with coverage effective the following January 1st.


26) Who is AccordantCare, and why did I receive something from them?

AccordantCare is a third party vendor that Sanford Health Plan has hired to assist members in specialized education and support programs for certain chronic diseases such as Multiple Sclerosis, Epilepsy, or Crohn’s Disease. Based on claims data received securely from Sanford Health Plan, AccordantCare will send introductory mailings and may call members asking if they are interested in participating in the free program.  Participation is voluntary.  Advantages of enrollment include: access to specialized nurses, assistance with care management, access to a specific patient portal with online educational resources, and more.  The AccordantCare Program can be reached at (844) 876-9869.

Medicare Members FAQ

1) Are retirees on the Dakota Retiree Plan (Medicare retirees) now required to go to a Sanford Health Plan network provider?
No. Just as you have with your previous carrier, Dakota Retiree Plan members must utilize Medicare-participating providers. Click here to view a listing of these providers.

2) What do I need to tell my health care provider about my new insurance company?
The only thing you need to do is show your new Sanford Health Plan ID card at your next appointment. Remember, you have the same Medicare Supplement (also known as a Medigap plan) Group Plan F as you did before. So there is no change to your benefits, Sanford Health Plan is simply acting as the new claims processor for NDPERS.

You are NOT in a Medicare Advantage Plan, HMO Plan, PPO Plan, Private Fee-for-Service (PFFS) Plan, Special Needs Plan (SNP), or PACE Plan. You are still on a Medigap Supplement Plan, like you had before.

3) What will my provider do with my new ID card?
As long as your doctor already participates in Medicare, they will use your ID card to submit the claim to Medicare on your behalf. Medicare will pay their portion of the claim and then automatically forward the claim to Sanford Health Plan. Medicare will know you have a new insurance company and the same benefits as before, because Sanford Health Plan sends Medicare an eligibility file that identifies all the NDPERS Dakota Retiree members as our new members and what plan you have. Using this file, Medicare is then able to match claims coming from your doctors and other healthcare providers, to Sanford Health Plan. Medicare will pay their portion of the claim and then automatically forward the claim to Sanford Health Plan to pay the rest – this is called the “cross-over” process.

4) What do I need to know as a Dakota Retiree member about this transition effective July 1, 2015?
You will continue to have a Medicare supplement product. Feel free to assure your provider that this carrier transition will still offer you a Medicare supplement product just as you have today. This means you can continue to see any Medicare participating providers and the coverage you have will not change. In regards to your prescription drug coverage, continue using your Medicare BlueRX card through December 31, 2015.

5) Will I have Medicare BlueRX after January 1, 2016?
No, your pharmacy coverage will change to Express Scripts Incorporated (ESI) beginning January 1, 2016. 

6) Will I receive a new prescription drug ID card for use after January 1, 2016?
Yes, you will receive a new prescription drug ID card, mailed to your home address prior to January 1, 2016.

7) Will my prescription costs change once I have Express Scripts Medicare after January 1, 2016?
Because pharmacies have unique and custom contracts, you may experience a different cost sharing amount for your prescriptions. Some members may have lower costs and others may experience higher costs. If you have a question about your medication, please contact the Express Scripts Medicare Customer Service number on the back of your member ID card. This service is available 24 hours a day, 7 days a week.

8) Will I be able to use the same prescriptions as I do today with the new drug coverage with Express Scripts Medicare?
Generally, Express Scripts Medicare will cover the same prescriptions that you have today, except when a new, less expensive drug becomes available or when the safety of effectiveness of the drug has changed. Express Scripts Medicare will notify your medication has been affected due to authorization requirements, quantity limits, or any other restriction; at least 60 days before the change becomes effective.

9) How will I know if my Medicare claims were crossed-over to Sanford Health Plan?
Once your provider submits your claim to Medicare, they will get a Medicare Remittance that shows your claim has been forwarded to Sanford Health Plan as your supplemental payer.

10) How will I know when my claim has been paid by both Medicare and Sanford Health Plan?
Medicare will mail you your Medicare Summary Notice (MSN) it shows all your Medicare-covered services or supplies that providers billed to Medicare, what Medicare paid, and the maximum amount you may owe the provider. On the “Notes for Claims” section of your MSN, it will indicate that your claim was sent to Sanford Health Plan as your supplement plan. Sanford Health Plan will also send you an Evidence of Benefits (EOB) showing the amounts we paid to the provider. Remember, neither the MSN nor the EOB are bills to pay you simply use these documents to match up the dollar amounts in the bill that your provider sends you (if there is any amount left to be paid).

11) How can BCBSND share data with Sanford Health Plan?
Under federal HIPAA privacy laws, “covered entities” such as a health insurance company, is permitted to use and disclose protected health information (PHI), without an individual’s authorization, for treatment, payment, and health care operations. These activities include determining eligibility or coverage, utilization review activities and claims management activities. Such information is always sent in a secured file format.

12) Is the upcoming change in how NDPERS administers the Retiree Health Insurance Credit (RHIC) due to the change of insurance carrier to Sanford Health Plan?
No, the change is not related to the carrier change. For information about the RHIC, please refer to http://www.nd.gov/ndpers/health-credit/retiree-health-credit-portability.html or contact NDPERS at (800) 803-7377 or (701) 328-3900.

13) What impact does the Supreme Court decision on same-sex marriage have on NDPERS Plan?
On June 26, 2015, the Supreme Court of the United States recognized that all couples have a fundamental right to marriage, regardless of their gender. In addition, each state must recognize a marriage that was entered into in a different jurisdiction, or state. In accordance with this court decision, NDPERS will make changes to your Certificate of Insurance and the eligibility requirements for spouses. You will receive a copy of the amendment in the mail. You must contact NDPERS to add your spouse and/or their children to your NDPERS Plan within the following timeframes:

  • 1. Same-sex marriages that occurred prior to June 26, 2015: NDPERS will have a special enrollment period from July 1, 2015 through September 30, 2015. Coverage will be effective retroactive to July 1, 2015. If the Subscriber does not enroll during this eligibility period, the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period with coverage effective the following January 1st.
  • 2. Same-sex marriages that occur on or after June 26, 2015: The Subscriber must submit an application for coverage to NDPERS within the first thirty-one (31) days of the event. If the Subscriber does not enroll when initially eligible, the Late Enrollee can only enroll during the next scheduled Annual Enrollment Period with coverage effective the following January 1st.

 

14) Who is AccordantCare, and why did I receive something from them?
AccordantCare is a third party vendor that Sanford Health Plan has hired to assist members in specialized education and support programs for certain chronic diseases such as Multiple Sclerosis, Epilepsy, or Crohn’s Disease. Based on claims data received securely from Sanford Health Plan, AccordantCare will send introductory mailings and may call members asking if they are interested in participating in the free program. Participation is voluntary. Advantages of enrollment include: access to specialized nurses, assistance with care management, access to a specific patient portal with online educational resources, and more. The AccordantCare Program can be reached at (844) 876-9869.

Contact Information

NDPER members and health care providers interested in more information about this partnership should email ndpers@sanfordhealthplan.com, complete the contact form below or call (701) 751-4125 or (800) 499-3416.
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