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. In an emergency, members are encouraged to proceed to the nearest participating emergency facility. If the emergency condition is such that a member cannot go safely to the nearest participating emergency facility, then members should seek care at the nearest emergency facility. The member or a designated relative or friend must notify the Plan and the member’s Primary Care Physician (if applicable) as soon as reasonably possible and no later than 48 hours after physically or mentally able to do so.
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: NOTE: Oncology treatment and services must be entered and authorized through eviti|Connect online at eviti.com.
- Members: Select “Ask a question” under “Contact Us” on your secure mySanfordHealthPlan account at member.sanfordhealthplan.org and click on the link for Utilization Management.
- Providers: “Authorizations” in your secure mySanfordHealthPlan account at provider.sanfordhealthplan.org/portal. Click on either “Submit a Pharmacy Preauthorization” or “Submit a Medical Preauthorization” depending on your request. Once you complete the required information click “Submit.”
- Phone: Call the appropriate number below and follow the menu prompts. Team members are available to take your calls from 8 a.m. to 5 p.m. CST, 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.
- North Dakota Medicaid Expansion members (855) 276-7214
- Commercial, Self-funded or Sanford Group Health members (800) 805-7938
- NDPERS members (888) 315-0885 (8 a.m. to 5:30 p.m. CST Monday-Friday)
- Fax: Providers: Send the Medical Prior Authorization Request Form and supporting documentation to (605) 328-6813.
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.
Prior Authorization List (As of 09/27/2018)
- 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.