Other Resources

Product Fact Sheets

  • elite1 Plans
  • Legacy Plans
  • Medicare Select Supplement
  • Medicare Supplement
  • ND Medicaid Expansion
  • NDPERS Active Plans
  • NDPERS Medicare
  • Third Party Admin TPA Group Plans
  • Sanford HOA
  • Sanford HOA Medicare Cost
  • Sanford True Plans
  • Signature Series Plans
  • Simplicity Plans

Forms

Simply click on the document below to open in Adobe and then you can review, print or save the document.

Claim Forms

Provider Demographic Forms

  • Provider Profile Form
  • Provider Update/Change Form
  • W-9 Form

Medical Management Forms

  • Benefit Coverage Consideration Request Form
  • Diabetes Eye Exam Consult Form
  • Formulary & Prescription Drug Prior Auth Request Exception Form
  • Health Management Program Referral Form
  • Medical Prior Authorization Request form
  • ND Medicaid Expansion Transition of Care Request Form
  • Sanford Health Heart of America Health Plan Referral Request Form

Facility and Provider Credentialing Applications

Note: Sanford Central Verification Office participates with the Minnesota Credentialing Collaborative, therefore accepts credentialing applications electronically through the site located at www.mncred.org.

  • Dental Credentialing Application
  • Facility Application
  • IA Provider Application
  • MN Provider Application
  • SD Provider Application

Clinical Practice Guidelines

Sanford Health Plan is responsible for adopting and distributing clinical practice guidelines for acute, chronic and behavioral health care services that are relevant to our membership. Clinical practice guidelines are systematically developed statements that help practitioners and members make decisions about appropriate health care for specific clinical circumstances. These guidelines can improve health care and reduce unnecessary variations in practice patterns. Practice guidelines are based on reasonable medical evidence, such as clinical literature and expert consensus. The Plan's multi-specialty physician committee, the Physician Quality Committee, has reviewed and approved practice guidelines for numerous conditions. Where links are provided, Sanford Health Plan has adopted the clinical practice guidelines exactly as they are written by the respective organizations. If you have any questions or suggestions regarding these guidelines or would like to request a copy of the guidelines, please visit the mySanfordHealthPlan provider portal or call the Health Plan at (800) 601-5086 or (605) 328-6877.

Clinical Practice Guidelines Adopted from Sanford Health

The following guidelines in this section were developed by the Sanford Clinical Practice Committee and adopted by Sanford Health Plan's Physician Quality Committee.

ADHD

  • Sanford Clinic Attention Deficit Hyperactivity Disorder (ADHD) (Age 6-18) Practice Guideline for Primary Care, Revised 04/06/2016

Appropriate Antibiotic Utilization
Pediatric

  • Pediatric Acute Bacterial Sinusitis (ABS) Guideline, Revised 02/06/2014
  • Pediatric Pharyngitis Guideline (Age 5-15 Years), Revised 12/22/2015
  • Pediatric Acute Otitis Media (AOM) Guideline (Children >2 Months of Age), Revised 07/28/2014

Adults

  • Adult Acute Bacterial Rhinosinusitis (ABRS) Guideline, Revised 02/05/2014
  • Adult Acute Pharyngitis Guideline (Age 16 Years and Older), Revised 03/05/2014
  • Adult Acute Bronchitis Guideline, Revised 03/05/2014
  • Adult Acute Exacerbation of Chronic Bronchitis (AECB) Outpatient Guideline, Revised 04/16/2014

Asthma

Breast Cancer Screening

  • Sanford Clinic Breast Density Mammogram Guideline, Revised 05/06/2015
  • Sanford Clinic Breast Cancer Screening Guideline, Revised 05/23/2016

Cervical Cancer Screening

  • Cervical Cancer Screening
  • Sanford Clinic Cervical Cytology Screening Guideline, Revised 08/22/2012

Congestive Heart Failure

  • Sanford Clinic Adult (Age ≥ 18) Heart Failure (HF) Guideline, Revised 12/04/2013 ARR

COPD

  • Sanford Clinic Adult Obstructive Pulmonary Disease (COPD) Practice Guideline, Revised 03/05/2014 ARR

Depression

  • Sanford Clinic Major Depression (Age ≥ 12) Practice Guideline, Revised 08/05/2014 ARR

Diabetes

  • Sanford Clinic Diabetes Practice Guideline, Revised 04/06/2016 ARR

Obesity
Adults

  • Sanford Clinic Adult Obesity (Age ≥ 18) Practice Guideline, Revised 08/07/2013 ARR

Children/Adolescents

  • Sanford Clinic Pediatric (Ages 3-17) Obesity Guideline, Revised 08/12/2013 ARR

Quality Improvement Program

This Hedis report is Sanford Health Plan's commitment to our customers that we will continue to provide cost effective, quality care and service.

Preventive Guidelines

  • Preventive Guidelines

Pharmacy Information

The Sanford Health Plan Formulary is a list of medications that are the most effective for the treatment and diagnosis of disease and maintenance of health according to the clinical judgment of the physicians, pharmacists and other health care professionals who serve on the Physicians Quality Committee that approved the formulary.

For a complete listing of the formulary and pharmacy management procedures (including things like generic substitution, prior authorization, step therapy protocols and more). Log on to your provider account here.

  • Summary of Pharmacy Benefits Booklet
  • Formulary (list of approved drugs)

What If a Prescription Drug Is Not On The Formulary?
Sanford Health Plan uses a Formulary to help members save money and help control the costs of healthcare. Of course, not all drugs are included in the formulary. However, we understand that sometimes exceptions must be made. A Medication Request Form can be used if:

  • You feel it's medically necessary to allow the member to take a drug that is not listed on our formulary; or
  • The member has tried our Step Therapy program and cannot tolerate the side effects or the use of the Step Therapy drugs are contraindicated and you would like authorization for coverage of those drugs.

If you have questions regarding our formulary, contact our Pharmacy Management Team at the numbers below:

Contact Us

  • Contact Us