Provider Manual

Table of Contents Section 1: Welcome...... 8 Section 2: About Sanford Health Plan (SHP)...... 9 2.1 Sanford Health Plan...... 9 2.2 Sanford Health Plan Corporate Organization...... 9 2.3 History of Sanford Health Plan...... 9 2.4 Expansion and Rapid Growth...... 10 2.5 SHP’s NCQA Accreditation...... 10 Section 3: Products & Services...... 11 3.1 Products & Services Overview...... 11 3.2 Service Area...... 11 3.3 Confidentiality & Disclosure...... 11 3.4 Fully Insured Commercial Products...... 12 3.4.1 Simplicity...... 12 3.4.2 Sanford TRUE...... 14 3.4.3 elite1 Plans...... 16 3.4.4 Medicare SELECT Supplement...... 18 3.4.5 Medicare Supplement Plans...... 20 3.4.6 Signature Series...... 21 3.4.7 Legacy Plans...... 23 3.5 Third Party Administrative Services to Sanford Health...... 25 3.6 Sanford Heart of America Health Plan...... 27 3.6.1 Commercial Products – Individual & Group...... 27 3.7 Sanford Heart of America Medicare Cost Product Health Plans...... 29 3.8 Government Products...... 30 3.8.1 North Dakota Medicaid Expansion...... 31 3.8.2 North Dakota Public Retirement System Medicare Supplement...... 34 3.8.3 North Dakota Public Employee Retirement System Non-Medicare...... 35

3 Section 4: Provider Relations...... 37 4.1 Contracting & Provider Relations Department...... 37 4.2 Contracting...... 37 4.3 Credentialing & Re-credentialing...... 37 4.3.1 Locum Tenans providers...... 38 4.3.2 Supervising Physician...... 38 4.4 Credentialed Providers...... 38 4.5 Practitioners Who Do Not need to be Credentialed/Re-credentialed...... 39 4.5.1 Inpatient Setting...... 39 4.5.2 Freestanding Facilities...... 39 4.5.3 Practitioners who are not accepted by Sanford Health Plan...... 39 4.6 Ongoing Monitoring Policy...... 40 4.7 Provider Rights & Responsibilities...... 40 4.7.1 Right to Review & Correct Credentialing Information...... 40 4.7.2 Refusing to Treat a Sanford Health Plan Member...... 41 4.7.3 Member Eligibility Verification...... 41 4.7.4 Medical Record Standards...... 41 4.7.5 Practitioner Office Site Quality...... 42 4.7.6 Cultural and Linguistic Competency...... 42 4.8 Primary Care Responsibilities...... 43 4.9 Access Standards...... 44 4.9.1 Primary Care Physician...... 44 4.9.2 Emergency Services...... 44 4.9.3 Urgent Care Situation...... 45 4.9.4 Ambulance Service...... 45 4.9.5 Out of Area Services...... 45 4.9.6 Treatment of Family Members...... 46 4.9.7 Provider Terminations...... 46 4.9.8 Notification of Provider Network Changes...... 46

4 Section 5: Quality Improvement & Medical Management...... 47 5.1 Quality Improvement Program...... 47 5.1.1 Complex Case Management Referral Guide Medical Management Program...... 47 5.2 Medical Management Program...... 48 5.2.1 Utilization Review Process...... 48 5.2.2 New Medical Service or Product Consideration...... 49 5.2.3 Prior Authorizations...... 49 5.2.4 Sanford Health Plan Referral Center...... 51 5.2.5 Coordinated Services Program (CSP)...... 51 5.2.6 Pharmacy Management and Formulary Program Information...... 52 5.2.7 Sanford Health Plan Formulary...... 52 Section 6: Filing Claims...... 53 6.1 Member Eligibility & Benefit Verification...... 53 6.1.1 North Dakota Medicaid Expansion Eligibility Adjustment ...... 53 6.2 Claims Submission...... 53 6.2.1 Paper Claims Submission...... 54 6.2.2 Corrected/Voided Claims Submission...... 54 6.3 Provider EDI Resources...... 55 6.3.1 EDI Services...... 55 6.3.2 EDI Enrollment...... 55 6.4 Instructions for Completing the CMS 1500...... 55 6.5 UB-04/CMS-1450 Claim Form & Instructions...... 58 6.6 Claims Payment...... 61 6.6.1 Process for Refunds or Returned Checks...... 61 6.7 Understanding your Check Adjustment Report...... 62 ` 6.8 How to Read your Explanation of Payment (EOP)...... 63 6.9 Provider Reimbursement...... 64 6.9.1 Participating Provider Reimbursement...... 64 6.9.2 Non-Participating Provider Reimbursement ...... 64 6.9.3 Modifiers...... 65 6.9.4 Claim Edits for Professional Claims...... 65

5 6.9.5 Inpatient Services...... 65 6.9.6 DRG Grouper for Inpatient Services...... 66 6.9.7 Skilled Nursing Health Levels of Care...... 66 6.9.8 Claim Reconsiderations...... 67 6.9.9 Proof of Timely Filing...... 67 6.10 Reporting Fraud, Waste, and Abuse (FWA)...... 67 6.11 Accident policy...... 68 6.12 Coordination of Benefits...... 69 6.12.1 Applicability...... 69 6.12.2 Order of Benefit Determination Rules...... 69 6.12.3 Non-Dependent/Dependent...... 69 6.12.4 Dependent Child Covered Under More Than One Plan Who Has Parents Living Together...... 70 6.12.5 Dependent Child of Separated or Divorced Parents Covered Under More than One Plan...... 70 6.12.6 Continuation of Coverage...... 70 6.13 Calculation of Benefits, Secondary Plan...... 70 6.14 Coordination of Benefits with Medicare...... 71 6.15 Coordination of Benefits with Medicaid...... 71 6.16 Coordination of Benefits with TRICARE...... 71 6.17 Members with End Stage Renal Disease (ESRD)...... 72 6.18 Billing Requirements...... 72 6.18.1 Multiple Surgeries...... 72 6.18.2 Bilateral Procedures...... 72 6.18.3 Assistant Surgeons...... 72 6.18.4 OB/GYN Global Package Billing/Antepartum Care...... 73 6.18.5 Newborn Additions...... 73 6.18.6 Never Events, Avoidable Hospital Conditions and Serious Reportable Events...... 73 6.18.7 Site of Service Differential...... 73 6.18.8 Anesthia ...... 74 6.18.9 Outpatient Pre-Labor Monitory Services ...... 75

6 6.18.10 Inpatient Services...... 75 6.18.11 DRG Grouper for Inpatient Services...... 76 6.18.12 Skilled Nursing Health Care Services...... 76 6.18.13 Home Health Care Services...... 77 6.18.14 Hospice & Respite Care Services...... 77 6.19 Ambulatory Payment Classification (APC) Payment...... 77 6.19.1 APC Payment Groups...... 78 6.19.2 APC Billing Rules ...... 78 6.19.3 APC Pricing Rules...... 79 6.19.4 OCE Edits...... 80 Section 7: Members ...... 82 7.1 Problem Resolution...... 82 7.1.1 Oral Complaint...... 82 7.1.2 Written Complaint...... 82 7.2 Appeals...... 83 7.2.1 Expedited Appeal...... 83 7.2.2 Prospective Appeal...... 83 7.2.3 Retrospective Appeal...... 83 7.3 Member Rights & Responsibilities...... 83 7.3.1 South Dakota, Iowa, Minnesota and North Dakota Member Rights...... 83 7.3.2 Minnesota Member Rights...... 84 7.4 Member Responsibilities for Minnesota, North Dakota, Iowa, and South Dakota...... 85 Section 8: Online Tools, Publications & Forms...... 87 8.1 mySanfordHealthPlan...... 87 8.2 Provider Directories...... 87 8.3 Forms...... 88 8.4 Sanford Health Plan ID Card & Benny Card...... 88 8.5 Provider Newsletters...... 88 Section 9: Appendix...... 89 9.1 Glossary of Terms...... 89 9.2 Modifiers...... 105 9.3 Place of Service Codes...... 111 7 Welcome Dear Sanford Health Plan Provider,

Sanford Health Plan welcomes you to our growing network of providers! This Provider Manual has been designed specifically for you to review prior to and as a reference tool after contracting with us. As a reference tool, you and your staff can learn about all our products, or reference our policies and procedures.

If you are viewing this as an electronic version, you can request a printed copy by contacting the Provider Relations Team at (800) 601-5086.

Thank you for your participation.

Sanford Health Plan

8 About Sanford Health Plan

2.1 Sanford Health Plan but also at what it means to its members and to what extent it has succeeded in meeting the Sanford Health Plan, headquartered in Sioux expectations associated with its customers. The Falls, South Dakota, is a non-profit, quality- Board of Directors is charged with guardianship driven, managed care organization that provides of the goals and the long-term vision of the products and services to individuals, businesses organization. and government entities. As part of an integrated health system, Sanford Health, we are uniquely To assure the success of Sanford Health Plan, positioned to understand the needs of patients, physicians and health care providers on the Board the challenges of health care providers, and the of Directors have a central role in the functioning demand of quality, affordable health care coverage of the Board as they participate in strategic for our employers, individuals and families. planning and policy development.

Since Sanford Health Plan’s inception in 1998, we 2.3 History of Sanford Health Plan have focused on building long-term partnerships. We also partner with local insurance agents in our In 1996, Sioux Valley Hospitals & Health System service area to offer products and services to meet formulated a corporate response to the changing their unique health insurance needs. In addition, health care marketplace, the rapid growth in the we are here to help our partners navigate the number of managed care service organizations, complexities of the dynamic health care industry and the need to meet the coverage requirements and regulatory environment. of Medicare-eligible residents within the organization’s tri-state service area. 2.2 Sanford Health Plan Corporate Organization A panel of health care professionals was assembled and charged with the responsibility Sanford Health Plan is a wholly owned, non-profit of researching, designing, and developing the subsidiary of Sanford Health. The Sanford Health requisite infrastructure for an outcomes-based Board of Trustees is ultimately responsible for health maintenance organization that would be the governance of Sanford Health Plan, but has recognized in the local marketplace and associated delegated to the plan’s Board of Directors authority with quality health care. The result was the to act as the governing body of the plan. The formulation of Sioux Valley Health Plan. In March President of Sanford Health Plan is accountable to 2007, Sioux Valley Health Plan changed its name the Sanford Health Plan Board of Directors. to Sanford Health Plan as a result of a generous gift of $400 million to Sioux Valley Hospitals & The Board of Directors acts as the conscience of Health System from South Dakota businessman, the Plan, looking not only at what the Plan does, T. Denny Sanford. 9 Subsequently, the Sioux Valley Board of Trustees 2.5 Sanford Health Plan’s NCQA unanimously voted to re-name the healthcare Accreditation system “Sanford Health” and Sioux Valley Health Plan was also renamed “Sanford Health Plan.” Sanford Health Plan is accredited with the National Committee for Quality Assurance (NCQA). Sanford Health Plan is a not-for-profit, community- Pursuing accreditation includes rigorous on-site based HMO that began operations in South Dakota and off-site evaluations for over 60 standards and on January 1, 1998. Managed care services are selected HEDIS® measures. NCQA implements provided to large and small groups in South performance-based scoring, requiring Sanford Dakota, North Dakota, and Iowa by Sanford Health Health Plan to report HEDIS® clinical quality Plan and in Minnesota by Sanford Health Plan of measures and CAHPS® patient experience Minnesota, which is a subsidiary of Sanford Health measures. These are the most widely used and Plan. Sanford Health Plan was designed to align respected tools for assessing quality of care and physicians and hospitals, establish a framework services in health care. for providers to efficiently manage the delivery of health care services, and operate on the strength NCQA publicly reports accreditation results of affordable premiums. in detailed Health Plan Report Cards and distinguishes performance through levels of Central to the design of Sanford Health Plan is accreditation. The organization regularly updates a collaborative effort between Sanford Health, its Health Plan Report Cards on plan performance contracted providers, and members of our service in five categories: “Staying Healthy,” “Getting area communities. Each of these elements offers Better,” “Living with Illness,” “Qualified Providers” unique perspectives, and the acknowledgment and “Access to Service.” that health care resources are finite. Accordingly, maintenance of the Plan’s financial viability is Quality is also demonstrated by our collaborative based upon the application of sound, balanced, and relationships with physicians, dentists, pharmacist efficient healthcare practices. and health care providers who serve on our board or participate on committees. By the assistance Sanford Health Plan was granted its Certificates of of these talented, highly educated and caring Authority in 1998 by South Dakota, Iowa and individuals, Sanford Health Plan continually strives Minnesota and by North Dakota in 2009. Central for excellence. health plan operations occur at its corporate office in Sioux Falls, South Dakota.

2.4 Expansion and Rapid Growth

In July 2013, Sanford Health Plan acquired Heart of America Health Plan located in Rugby, North Dakota. In July 2014, Sanford Health Plan was awarded the two-year contract for the North Dakota Public Employee System (NDPERS). As part of our ongoing commitment to serve our members, Sanford Health Plan expanded to offices in Fargo and Bismarck, North Dakota in May 2015.

10 Products & Services

3.1 Products & Services Overview Health Plan only to the extent the information is necessary for the Health Plan to ensure efficient Sanford Health Plan offers a suite of products to high quality care and services to its members. individuals, businesses and government agencies According to HIPAA Privacy Regulation 164.506 (c) to provide health care coverage in the form of (4), a covered entity may disclose protected health products and services. Our products and services information to another covered entity for certain can be divided in to four basic categories: fully health care operations of the entity that receives insured individual and group products, third party the information if each entity has or has had a administration, Heart of America products and relationship with the patient who is the subject of government products. the information and the information pertains to the relationship and the disclosure is for quality- We also offer the Advantage Discount Card related health care operations (including HEDIS program through our partner Careington medical record requests) or detection of fraud International Corporation to individuals and and abuse or other compliance-related activities. small employer groups. This discount program Consequently, the disclosure of medical records will include discounts for dental expenses, vision between the Health Plan and you as a provider expenses, hearing expenses and weight loss can take place without a signed authorization from programs/services at Profile by Sanford. the patient as this falls under the HIPAA definition of health care operations between covered 3.2 Service Area entities.* The records reviewed by the Plan are kept completely confidential and member specific Our licensed service area is North Dakota, South information is not provided to outside sources, Dakota and select counties in Minnesota and Iowa. including employers. For members outside of our service area, we may offer the Private Health Care Systems (PHCS) and Sanford Health Plan’s responses to information MultiPlan national networks. requests will reflect a customer service orientation, but will also reflect an awareness of 3.3 Confidentiality and Disclosure the potentially competing interests of the different categories of our customers (e.g., employer groups Sanford Health Plan protects the privacy of and enrolled employees). all patient and provider information in its administrative functions and among its contracted In addition, the Plan’s responses to these requests health care providers. Use of a patient’s personally will be consistent with the Plan’s legal obligations, identifiable health information for any purpose under the law and by contract. will have a clear and specific consent provided by the patient. Specific provider and member/patient *Certain Minnesota laws may require additional patient release forms. information is collected and used by Sanford

11 3.4 Fully Insured Commercial Products

Sanford Health Plan offers the following products to individuals, small groups, and large groups through the Exchange at healthcare.gov. Sanford Health Plan’s commercial products are as follows:

• Individuals: Simplicity, elite1* • Small business: Simplicity, TRUE, Signature Series*, Legacy Plans* • Large group: Signature Series, Legacy Plans*, High Deductible HSA compatible plans • We also offer the following ancillary products: Flex, HRA’s, HSA’s

* denotes plans are no longer being sold, only renewed.

3.4.1 Simplicity Plans

Plan Type

The Simplicity plans were developed after the Affordable Care Act (ACA) and are compliant with all the ACA regulations. These non-grandfathered plans are sold by local agents in the communities we serve and also available on the Marketplace at healthcare.gov. The Simplicity plans offer individuals and small employers a variety of options to meet their needs and budget. The plans vary in deductibles, coinsurance and co-pay options as well as maximum out-of-pocket expenses.

Simplicity individual plans: Offered only in North Dakota and South Dakota. Individuals can purchase plans directly with Sanford Health Plan or through the Marketplace at healthcare.gov where they may qualify for financial assistance.

Simplicity small group employer plans: Offered in North Dakota, South Dakota, Western Minnesota and Northwest Iowa. Small group employers can purchase plans directly with Sanford Health Plan or through the Small Business Health Options Program (SHOP) at healthcare.gov.

12 Provider Network

The network for these plans consists of over 20,000 providers, including the MultiPlan national network (when traveling). Members can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Remember that members will pay more if they seek services from a provider not listed in this directory.

To access the provider directory, go to sanfordhealthplan.com. 1. On the home page, click on “Providers - Find a Provider” and select “Learn More.” 2. On the directory home page, enter the first 9 digits of the patient’s Member ID number and last name OR select Individual-Simplicity or Group-Employer Large & Small from the drop down menu

Eligibility, benefits and claims status

Providers can create a secure online account to access eligibility, claims status and benefit information. Or, providers can call Customer Service at (800) 752-5863 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

Providers will be paid according to their contract. For questions about payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

How to request Prior Authorization

Prior authorizations for pharmacy and health care services can be obtained by contacting Utilization Management online, by phone or fax: NOTE: Oncology treatment and services must be entered and authorized through eviti|Connect online at eviti.com.

Online: Select “Authorizations” in your secure mySanfordHealthPlan account at sanfordhealthplan. com/providerlogin. Click on 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 (800) 805-7938 and follow the appropriate menu prompts. Team members are available 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.

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

13 3.4.2 Sanford TRUE

Plan type

Sanford TRUE is our ACA qualified focussed network plan offered to individuals and families living in the following states and counties: • South Dakota: Brown, Minnehaha, Lincoln. • North Dakota: Burleigh, Morton, Oliver, Cass, Traill.

This plan offers a lower premium cost to our members. There is no coverage for out-of-network services, except for emergencies. Individuals and families can purchase Sanford TRUE plans through local agents, directly with Sanford Health Plan, or through the Marketplace at www.healthcare.gov where they may qualify for financial assistance.

Provider network

The network for this plan consists of over 2,200 providers in the specific counties, with access to ALL Sanford providers in the region. This plan does not have out-of-network benefits.

To access the provider directory, go to sanfordhealthplan.com. 1. On the home page, click on “Providers - Find a Provider” and select “Learn More.” 2. On the directory home page, enter the first 9 digits of the patient’s Member ID number and last name OR select Individual-Sanford TRUE or Group-Sanford TRUE from the drop down menu

Eligibility, benefits and claims status

14 Claims and payment methodology

Claims should be submitted to Sanford Health Plan,preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

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.

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

15 3.4.3 elite 1 Plans

Plan type

Our elite1 plans are grandfathered plans that were developed before the ACA and are no longer actively sold. However, you may still see members who are enrolled in these grandfathered plans.

Provider network

The network for this plan consists of over 20,000 providers, including the MultiPlan national network (when traveling). Members can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Remember that members may pay more if they seek services from a provider not listed in this directory.

To access the provider directory, go to sanfordhealthplan.com. 1. On the home page, click on “Providers - Find a Provider” and select “Learn More.” 2. On the provider directory home page, enter the first 9 digits of the patient’s Member ID number and last name OR select Individual-Simplicity from the drop down menu.

Eligibility, benefits and claims status

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

16 How to request Prior Authorization

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

17 3.4.4 Medicare SELECT Supplement

Plan type

Our Medicare Select plan is a standard Medicare supplement plan that requires members to use Sanford Health Plan contracted facilities for non-emergency hospital and surgical care (Part A). When members enroll in Sanford SELECT, they agree to use Sanford’s SELECT network. Members can see any physician (Part B) and are not restricted to a network. Local insurance agents sell Medicare Select to individuals who have Medicare Part A and B in the following states and counties:

• South Dakota greater region: Aurora, Beadle, Bon Homme, Brookings, Brule, Buffalo, Charles Mix, Clay, Codington, Davison, Day, Deuel, Douglas, Grant, Gregory, Hamlin, Hanson, Hutchinson, Jerauld, Kingsbury, Lake, Lincoln, Lyman, McCook, Miner, Minnehaha, Moody, Roberts, Sanborn, Spink, Tripp, Turner, Union or Yankton. • South Dakota Aberdeen region: Brown, Edmunds, Faulk, Marshall or McPherson • North Dakota: Barnes, Burleigh, Cass, Dickey, Emmons, Grand Forks, Grant, Griggs, Kidder, LaMoure, Logan, McIntosh, McLean, Mercer, Morton, Nelson, Oliver, Ransom, Richland, Sargent, Sheridan, Sioux, Steele or Traill. • Iowa: Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola or Sioux • Minnesota: Cottonwood, Jackson, Lac Qui Parle, Lincoln, Lyon, Martin, Nobles, Murray, Pipestone, Redwood, Rock, Watonwan or Yellow Medicine

Provider network

The plan members can receive services from any providers accepting assignment (payment) from Medicare. Members should to seek services from in network facilities in order to receive maximum benefits. Facility expenses for members who receive non-emergency services at a non-network hospital or outpatient surgery center will be denied.

18 Eligibility, benefits and claims status

Claims and payment methodology

Providers should bill Medicare as primary and Sanford Health Plan as secondary.

19 3.4.5 Medicare Supplement Plans

Plan type

Our Medicare Supplement plans are standard supplement plans and do not require the members to use a specific network. These plans are sold by local agents to individuals with Part A and Part B Medicare coverage in the following states and counties: • South Dakota: All counties • North Dakota: All counties • Iowa: Clay, Dickinson, Emmet, Lyon, O’Brien, Osceola or Sioux • Minnesota: Cottonwood, Jackson, Lac Qui Parle, Lincoln, Lyon, Martin, Nobles, Murray, Pipestone, Redwood, Rock, Watonwan or Yellow Medicine

Provider network

The Plan members can receive services from any providers accepting assignment (payment) from Medicare. There is no network with Sanford Supplement Plan.

Eligibility, benefits and claims status

Providers will be paid according to their contract. For questions about payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology

Providers should bill Medicare as primary and Sanford Health Plan as secondary.

20 3.4.6 Signature Series

Plan type

Our Signature Series plans are sold to large employer groups through local community agents in South Dakota, North Dakota, northwest Iowa and western Minnesota. Employers are able to create their own unique benefits by selecting from a vast array of deductible, copay and out of pocket options that fit the insurance needs of their organization.

Provider network

Eligibility, benefits and claims status

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110. You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 605-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

21 How to request Prior Authorization

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813. A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

22 3.4.7 Legacy Plans

Plan type

Our Legacy plans, such as Classic 1500, are grandfathered or transitional plan sold prior to the ACA. They are no longer being sold, however you may still see members who are enrolled in these plans. Eventually, these businesses may lose or give up their ACA grandfathered status to purchase a plan that meets the Affordable Care Act requirements.

Provider network

The network for these plans consist of over 20,000 providers, including the MultiPlan national network (when traveling). Members can choose to see any licensed provider for covered services without a referral, whether the provider is in-network or out-of-network. Remember that members will pay more if they seek services from a provider not listed in this directory.

To access the provider directory, go to sanfordhealthplan.com. 1. On the home page, click on “Providers - Find a Provider” and select “Learn More.” 2. On the directory home page, enter the first 9 digits of the patient’s Member ID number and last name OR select Group-Employer Large & Small from the drop down menu.

Eligibility, benefits and claims status

Providers will be paid according to their contract. For questions about payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

23 How to request Prior Authorization

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

24 3.5 Third Party Administrator (TPA) Services:

Sanford Health Plan provides third party administrator (TPA) services to employer sponsored self-funded health plans. Benefits are determined by the client, not by the TPA, with the client absorbing the claims risk.

Plan Type

These services include claims adjudication, customer service functions, provider relations and medical management. Benefits are determined by the employer group, not Sanford Health Plan.

Provider network

Eligibility, benefits and claims status

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

25 How to request Prior Authorization

26 3.6 Sanford Heart of America Health Plan:

Sanford Health Plan affiliated with Heart of America Health Plan in 2013. The products are grandfathered plans developed and sold prior to the ACA products for individuals, families, and commercial products for small group and large group. They are still offered renewals; however products are not actively sold. The Medicare Cost product is an active product.

3.6.1 Commercial Products Individual & Group

Plan type

Sanford Heart of America Health Plan health insurance plans are only being renewed and not actively sold to employer groups, families and individuals in the Rugby, Minot, and Bottineau service area.

Provider network

The network for this plan consists of providers surrounding the Minot and Rugby area, and ALL Sanford providers in the region. You can choose to see any licensed provider for covered services without a referral. Remember that you will pay more if you seek services from a provider not listed in this directory.

Eligibility, benefits and claims status

Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

You will be paid according to your contract. For questions about provider payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

27 How to request Prior Authorization

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

28 3.7 Sanford Heart of America Medicare Cost Product Health Plan

Plan type

Sanford Heart of America Health Plan offers health insurance plans to Medicare eligible individuals in North Dakota in the counties of: Burleigh, Morton, and Oliver. The service area includes these parts of counties in North Dakota: Benson, Bottineau, McHenry, Pierce, Rolette, Towner, and Wells, in the following zip codes only: 58313, 58316, 58317, 58318, 58323, 58324, 58329, 58331, 58332, 58337, 58341, 58343, 58346, 58348, 58352, 58353, 58357, 58359, 58363, 58365, 58366, 58367, 58368, 58369, 58372, 58377, 58384, 58385, 58386, 58418, 58422, 58438, 58710, 58712, 58713, 58736,58740, 58741, 58744, 58748, 58758, 58762, 58778, 58783, 58788, 58789, 58792, 58793.

Provider network

Eligibility, benefits and claims status

Providers can create a secure online account at sanfordhealthplan.com/providerlogin to access eligibility, claims status and benefit information. Or, providers can call Customer Service at (800) 752-5863 from 8 a.m. to 5 p.m. CST, Monday through Friday.

Claims and payment methodology

Providers who are contracted with Sanford Heart of America Health Plan and bill for professional services, are to submit claims to Sanford Health Plan as primary and Medicare as secondary. For all other services, Providers should bill Medicare as primary and Sanford Health Plan as secondary.

29 3.8 Government Products:

With proficiency as an insurance company and TPA, combined with our unique perspective as part of an integrated health care system, we are able to provide solutions to government agencies. Sanford Health Plan has two different government products: North Dakota Medicaid Expansion and North Dakota Public Employee Retirement System (NDPERS).

3.8.1 North Dakota Medicaid Expansion

Plan Type

To fill gaps in the coverage for some individuals, the Affordable Care Act (ACA) created a new Medicaid group, called “Medicaid Expansion.” The new expansion program allowed about 20,000 residents in North Dakota to enroll in gain health insurance coverage. The North Dakota Department of Human Services (ND DHS) contracted with Sanford Health Plan beginning January 1, 2014 to administer benefits to Medicaid Expansion members. ND DHS manages the application process, and eligibility determination. Sanford Health Plan manages the following services: medical management, claims adjudication, customer service, pharmacy network and claims, provider relations and provider network. As of January 1, 2018, all providers, pharmacies, suppliers and transportation providers must be enrolled with the ND DHS MCO program to receive payment from Sanford Health Plan on any claims specific to North Dakota Medicaid Expansion recipients. Please note the State of North Dakota’s Traditional Medicaid program and the program administered by Sanford Health Plan, known as North Dakota Medicaid Expansion, operate under different systems.

North Dakota Medicaid Expansion enrollment guidance for providers is available at www.sanfordhealthplan. com/providers/2018-NDME-Network-Changes. Enrollment with the ND DHS Medicaid program does not require a provider to render services to ND Fee-for-Services recipients. However, federal regulations [42 CFR §438.602(b)] requires Sanford Health Plan to confirm enrollment with ND DHS prior to payment for dates of service after January 1, 2018.

Provider network

This plan is offered to members covered by North Dakota (ND) Medicaid Expansion only. As of January 1, 2018, the network for this plan consists of contracted providers and pharmacies who have completed enrollment with the state of ND Medicaid Program and are located within the defined ND Medicaid Expansion (NDME) service area. This plan does not have out-of-network benefits.

30 NDME Medical service area: includes providers located in North Dakota and counties that border North Dakota in Montana, Minnesota, and South Dakota. NDME Pharmacy service area: includes pharmacies located in North Dakota, South Dakota, Minnesota, and Montana.

Eligibility and benefits

Individuals can apply: • Online at apply.dhs.nd.gov; • By paper application which can be completed online, printed and mailed; • By telephone (855) 794-7308 or ND Relay TTY (800) 366-6888; or • In-person at a North Dakota county social service office.

Individuals eligible for this coverage must meet the following criteria: • Are between the ages of 19 through 64; • Have incomes below 138% FPL (for a single person, that’s an annual income of $15,856); • Are legal U.S. residents; • Are not incarcerated; and • Are not entitled or enrolled in Medicare or traditional Medicaid.

All eligibility determinations and enrollment is done by the North Dakota Department of Human Services. Sanford Health Plan does not determine who is eligible for this program or when enrollment occurs. Once the State determines eligibility, enrollment information is sent to Sanford Health Plan for processing. Please note: Sanford Health Plan may be notified by NDDHS that a member has lost eligibility retroactively. When this happens, federal regulations require Sanford Health Plan, as the MCO, to recoup payments made on an individual determined by the state of North Dakota to be ineligible for coverage.

Claims and payment methodology

31 Medicaid Expansion schedule of benefits

Medicaid Expansion members are responsible for the following copayments unless the following criteria are met: • Members ages 19 and 20, are exempt from all co-payments • Pregnant women are exempt from all co-payments • Getting birth control drugs or devices do not require a co-payment • A Native American member who can get, or is eligible to get, services from Indian Health Services (IHS) or through referral by Contract Health Services (CHS), is exempt from all co-payments • Members are exempt from co-payments if they are residing in institutions such as: º Nursing Facility, long term care º Swing bed, long term care º Intermediate Care Facility for the Intellectually Disabled (ICF/ID) º State Hospital

Benefits Coverage Description In-nework Co-payment

Out-of-pocket maximum limit for each This is the most a member would payout of pocket each year. Members will receive a letter telling 5% of the household’s countable earnings calendar year them when they have reached this limit. Medical office visit $0 for 19 and 20 year olds Covered. Includes visits to physicians, nurse $2 for each office visit practitioners and physician assistants

Rural health clinic visit Covered.

Federally Qualified Health Center Visit Covered.

Preventive care office visit Covered. Immunizations for travel purposes not $0 for each office visit Includes health screenings, prenatal and covered. postpartum care, and routine immunizations Diagnostic tests Covered. $0 for each office visit Includes x-rays, blood work, MRIs $0 for 19 and 20 year olds Covered. You must call to get prior-approval. Inpatient hospital stay $75 for each stay for members 21 and older Outpatient surgery Covered. You must call to get prior-approval. $0 Home health care Covered. You must call to get prior-approval. $0 Skilled nursing facility services Covered. You must call to get prior-approval. $0 Outpatient mental/behavioral health/ substance use disorder $0 for 19 and 20 year olds. $2 for each visit for Covered. Includes medical office visits to physicians, nurse members 21 and older. practitioners and physician assistants You must call to get prior-approval. Including $0 for 19 and 20 year olds. Inpatient mental health services Covered for 19 and 20 year olds. alcohol and drug treatment. Includes overnight hospital stays, residential care. $2 for each visit for members 21 and older. Covered at certain hospitals only for members 21 and older.

Durable medical equipment and Covered. $0 prosthetic devices You must call to get prior-approval. Covered. $0 Hospice care You must call to get prior-approval.

32 Benefits Coverage Description In-nework Co-payment Habilitation & rehabilitation services Covered. Limits apply only for members ages 21 and older.

Physical therapy office visit $0 for 19 and 20 year olds 30 visits per therapy per calendar year $2 for each visit for Members ages 21 and older

Occupational therapy office visit $0 for 19 and 20 year olds 30 visits per therapy per calendar year $2 for each visit for Members ages 21 and older

Speech therapy office visit $0 for 19 and 20 year olds 30 visits per therapy per calendar year $1 for each visit for Members ages 21 and older

Habilitative therapy office visit $0 for 19 and 20 year olds 30 visits per therapy per calendar year $2 for each visit for Members ages 21 and older Covered for spinal manipulations.Limited to 20 $0 for 19 and 20 year olds $1 for each visit Chiropractic care visits per calendar year Dental office visits Covered for 19 and 20 year olds. $0 for each office visit nnual routine exam covered for 19 and 20 year $0 for 19 and 20 year olds Eye exam olds and members with diabetes.

Covered for members 21 and older for non- Office visit includes optometrists and $2 for each office visit for Members ages 21 routine vision exams relating to eye disease or ophthalmologists and older injury of the eye.

Foot exam office visit $0 for 19 and 20 year olds Covered. $3 for each office visit for Members ages 21 Includes podiatrists and older Emergency room visit Covered. $0 Emergency transportation Includes ground and air ambulance services Covered. $0 for use in an emergency. Non-emergency transportation Covered. You must call to get prior-approval. $0 Prescription drugs

Drugs listed on the formulary and/or prior Covered. authorized by the Plan Generic Drugs $0 copay per 30-day supply

Diabetic Supplies $0 copay per 30-day supply

Brand Name Drugs & Diabetic Supplies $3 copay per 30-day supply

Not covered

Drugs not listed on the formulary and not prior authorized by the Plan

How to request Prior Authorization

Fax: Send the Medical Prior Authorization Request form and supporting documentation to (605) 328-6813.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin. 33 3.8.2 North Dakota Public Retirement System (NDPERS) Medicare Supplement

Plan type

The North Dakota Public Retirement System (NDPERS) selected Sanford Health Plan as its new insurance carrier effective July 1, 2015. Sanford Health Plan provides medical coverage for both the non-Medicare and Medicare Supplement members. Total covered lives, including spouses and dependents, average 65,000.

Retirees can opt to enroll in the NDPERS Medicare supplement plan if they have both Medicare Parts A and B; this includes those under 65 if they are on Social Security Disability and have both Medicare Parts A and B. Members who have the NDPERS Medicare Supplement plan will present an ID card with their specific information.

Provider network

NDPERS Medicare Supplement plan members can receive services from any provider accepting assignment (payment) from Medicare.

Eligibility, benefits and claims status

The staff members at NDPERS will continue to administer the enrollment and eligibility.

Claims and payment methodology

Providers should bill Medicare as primary and Sanford Health Plan as secondary.

34 3.8.3 North Dakota Public Employees Retirement System (NDPERS) Non-Medicare Plans

Plan type

The North Dakota Public Employees Retirement System (NDPERS) selected Sanford Health Plan as its new insurance carrier effective July 1, 2015. Sanford Health Plan will provide medical coverage for both the non-Medicare and Medicare members. Total covered lives, including spouses and dependents, are approximately 65,000.

The non-Medicare members have three plans options: grandfathered, non-grandfathered and high deductible. All non-Medicare members will present an ID card with their specific information on the card. Medicare supplement members will present with a different ID card.

Provider network

This plan is offered to members employed with NDPERS ONLY. The network for this plan consists of both PPO and Basic networks, including the MultiPlan national network (when traveling).

Eligibility, benefits and claims status

The staff members at NDPERS will continue to administer the enrollment and eligibility.

35 Claims and payment methodology

Claims should be submitted to Sanford Health Plan, preferably electronically using Payor ID 91184. Paper claims can be submitted to Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110.

Providers will be paid according to their contract. For questions about payment, call Provider Relations at (800) 601-5086 from 8 a.m. to 5 p.m. CST, Monday through Friday.

How to request Prior Authorization

Phone: Call (888) 315-0885 and follow the appropriate menu prompts. Team members are available from 8 a.m. to 5:00 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: Send the Medical Prior Authorization Request form and supporting documentation to (701) 234-4547.

A list of services requiring prior authorization can be found online at sanfordhealthplan.com/providerlogin.

36 Provider Relations

4.1 Provider Relations Department sanfordhealthplanprovidercontracting@ sanfordhealth.org. Our Provider Relations staff members are here to help you with your questions regarding contracting/ Sanford Health Plan partners with Careington credentialing, or questions related to claims International Corporation in offering a discount payment. card program to our individual and small employer groups (both on and off the Marketplace). The Phone: (855) 263-3544 or email to Careington discount program is not insurance Email: [email protected]. and is separate from an agreement with Sanford Health Plan. For dental, vision and audiology 4.2 Contracting Department providers wanting to get more information on joining Careington International Corporation’s discount In order to provide a full range of health care card program, you can contact a Careington services to our members, our provider relations recruiter at (800) 441-0380 ext. 7143. department annually evaluates our network against our access and availability standards and 4.3 Credentialing and Re-credentialing state requirements. We contract with physicians, Credentialing is the process of verifying that an hospitals and other health care providers for applicant meets the established standards and appropriate geographic access and to ensure qualifications for consideration in the Sanford sufficient capacity throughout the entire service Health Plan network. Initial credentialing is area. In addition, we annually assess the cultural, performed when an application is received. ethnic, racial and linguistic needs of our members Re-credentialing is performed every three years. to ensure the availability of bilingual practitioners In general, the credentialing and re-credentialing process applies to: To become a participating provider, a contract and fee schedule must be signed. A completed • Practitioners who have an independent credentialing application and W-9 form is also relationship with the organization. required. When the facility or provider has been • Practitioners who see members outside the approved through the credentialing process, inpatient hospital setting or outside free- providers are granted participating provider status, standing ambulatory facilities. allowing them to appear in our online provider • Practitioners who are hospital based, but who directory. see the organization’s members as a result of their independent relationship with the The contracting department can be contacted organization. by phone: (855) 263-3544; or email:

37 • Non physician practitioners who have an 4.3.2 Supervising Physician independent relationship with the organization who can provide care under the organization’s A Supervising Physician is a licensed physician medical benefits. in good standing who, pursuant to US State regulations, engages in the direct supervision of During the initial credentialing period, providers a practitioner with limited licensure. Claims using should submit claims to Sanford Health Plan. the supervising physician’s name and provider However, all claims for the provider will be pended number can be used where the practitioner is still until the credentialing process is complete. Once the working towards licensure, or has limited licensure. provider is approved by the credentialing committee, Supervising physicians may not bill separately for the pended claims will release for processing. services already billed under these circumstances, unless there are personal and identifiable services Claims must be submitted within 180 days from the provided by the teaching physician to the patient date of service or as defined by your contract. The they performed in management of the patient. following policy(s) are referenced in this section and Sanford Health plan does not require PA’s or are available for review under “Provider Resources” APRN’s to bill with the name of their supervising at sanfordhealthplan.com/providerlogin. physician on the claim form.

• Practitioner Credentialing Policy (PR-06) 4.4 Credentialed Providers • Criteria for Participating Providers (PR-10) • Institutional Provider Credentialing Policy The following types of practitioners are eligible (PR-20). for Participating Provider status provided that they possess and provide satisfactory evidence 4.3.1 Locum Tenans Providers as required through the Sanford Health Plan credentialing process. The types of practitioners Locum Tenans arrangement is when a physician is requiring credentialing by Sanford Health Plan retained to assist the regular physician’s practice include, but are not limited to: for reason such as illnesses, pregnancy, vacation, staffing shortages or continuing medical education. • Doctors of Allopathy Locum Tenans generally have no practice of their • Doctors of Osteopathy own and travel from area to area as needed. Locum • Physician Assistants * Tenans who are providing coverage for a physician • Nurse Practitioners * for 60 consecutive days or less do not need to be • Podiatrists fully credentialed. However, if the Locum Tenans • Chiropractors cover for periods longer than 60 consecutive days, • Optometrists Sanford Health Plan will require the provider to • Audiologists (master’s level or higher) complete the credentialing process and they will no • Speech Pathologists longer be allowed to bill with the absent provider’s • Physical Therapists NPI. • Occupational Therapists • Dentists • The locum tenans provider must submit • Oral/Maxillofacial Surgeons claims using the provider NPI and tax ID of the • Nurse Anesthetists physician for whom the locum tenans provider (nonhospital based or independent relationship) is substituting or temporarily assisting. • Other practitioners with Master’s level training • Bill with modifier Q6 in box 24d of the CMS-1500 or higher who have an independent relationship form for each line item service on the claim with Sanford Health Plan • The code(s) being billed must qualify for the Q6 • Locum Tenens providers who have practiced in modifier for payment the same location or on a contracted period of more than 60 consecutive days • Behavioral Health Practitioners

38 o Psychiatrists 4.5 Practitioners Who Do Not Need to be o Psychologists (doctoral or master’s level Credentialed/Recredentialed who are state certified or licensed) o Social Workers (master’s level or higher who 4.5.1 Inpatient Setting are state certified or licensed) o Addiction medicine specialists Practitioners who practice exclusively within the o Clinical nurse specialists or psychiatric inpatient setting and who provide care for members nurse only as a result of an inpatient stay do not need to be practitioners (master level or higher who are credentialed. Examples include: nationally or state certified or licensed) • pathologists o Other behavioral healthcare specialists who • radiologists are licensed, certified or registered by the • anesthesiologists state to practice independently • neonatologists • Residents in his/her third or fourth year of • emergency room physicians residence training. Credentialing cycle will end • hospitalists 60 days after estimated residency completion • board certified consultants date. A recredentialing cycle will be completed • locum tenens physicians who have not to include residency verification. practiced at the same facility for 60 or more • Anesthesiologist with pain management consecutive calendar days and do not have an practices independent relationship with Sanford Health • Clinical nurse specialists (master level or Plan higher who are nationally or state certified • nurse anesthetists (hospital based) or licensed.)* • Advanced Practice Registered Nurses ( 4.5.2 Freestanding Facilities master level or higher who are nationally or Practitioners who practice exclusively within state certified or licensed.) freestanding facilities and who provide care • Telemedicine practitioners who have an for members only as a result of members independent relationship with the organization being directed to the facility do not need to be and who provide treatment services under the credentialed. Examples include: organizations medical benefit. Practitioners providing medical care to patients located • Mammography centers in another state are subject to the licensing • Urgent care centers and disciplinary laws of that state and must • Surgical-centers possess an active license in that state for their • Ambulatory behavioral health care facilities professions. (i.e. psychiatric and addiction disorder clinics) Practitioners who are not accepted by Sanford Nurse Midwives, Nurse Practitioners, Physician Health Plan Assistants and Clinical Nurse Specialist must have an agreement with a licensed physician or physician 4.5.3 Practitioners who are not accepted by group unless the state law allows the practitioner to Sanford Health Plan practice independently. This is in reference to H.R. The following listing of practitioner types will not 3590 – Patient Protection and Adorable Care Act be credentialed: C. 2706, non-discrimination in health care and 42 • Registered Nurses U.S.C. 300gg-5. Non-discrimination in health care. • Licensed Practical Nurses State laws requiring collaborative agreements will • Practitioners not providing all required be required by Sanford Health Plan. documentation in addition to a completed and attested to credentialing application • Practitioners who have not yet received their required license by their state

39 • Practitioners who are currently on a leave of practitioner a one-year re-credentialing cycle. absence. In the event that the practitioners The Committee may also decide other courses of credentialing cycle expired during the leave of improvement based on the evidence provided. absence, the practitioner must reapply within 30 days of returning to practice. In the event that the Committee determines that • Providers excluded from participation in federal the practitioner possesses serious quality issues health care programs under either section 1128 and is no longer fit to participate in the network, or section 1128A of the Balanced Budget Act the practitioner will be sent formal appeal rights. of 1997 or any provider excluded by Medicare, If the final result is termination of that practitioner Children’s Health Insurance Program, or from the Sanford Health Plan provider network, Medicaid the appropriate agencies will be contacted.

4.6 Ongoing Monitoring Policy All decisions made by the Sanford Health Plan Credentialing Committee are reviewed and Sanford Health Plan identifies and takes appropriate approved by the Sanford Health Plan Board of action when practitioner quality and safety issues Directors. are identified. Sanford Health Plan monitors ongoing practitioner sanctions or complaints The following policy(s) are referenced in this between re-credentialing cycles. Sanford Health section and are available for review under Plan, and its delegates, will monitor on an ongoing “Provider Resources” at sanfordhealthplan.com/ basis: providerlogin.

1. Medicare and Medicaid sanctions • Monitoring Policy (PR-24) 2. State sanctions or limitations on licensure 3. Complaints against practitioners 4.7 Provider Rights & Responsibilities 4. Adverse events 4.7.1 Right to Review and Correct Sanford Health Plan will delegate this responsibility Credentialing Information to its contracted delegates as long as the processes in those policies meet the intent of NCQA and Practitioners have the right to review information Sanford Health Plan standards. A practitioner in submitted in support of their credentialing good standing means that no sanctions can be applications, however, Sanford Health Plan identified through the Office of Inspector General respects the right of the Peer Review aspects (OIG), state sanctions or complaints to that that are integral in the credentialing process. specific practitioner. When sanctions are identified Therefore, practitioners will not be allowed to between re-credentialing cycles or the number review references or recommendations or any other of Quality Risk Issues exceeds the Sanford Health information that is peer review protected. All other Plan threshold of five within two years, then the information obtained from an outside source is practitioner will be presented to the Sanford Health allowed for review. Plan Credentialing Committee through formal re-credentialing so the sanctions and/or complaints If during the review process, a practitioner can be peer reviewed. discovers an error in the credentialing file, the practitioner has the right to correct erroneous Sanford Health Plan Credentialing Committee information. The practitioner will be allowed 10 reviews all sanctions, limitations of licensure days to provide corrected information. Sanford and complaints. The Committee determines Health Plan will accept corrected information over the appropriate interventions when instances of the phone, in person, or via voice mail. Corrected poor quality are identified. Recommendations to information must be submitted to the appropriate approve the practitioner with additional education Credentialing Specialist who is processing the file. or required supervision, or may require the

40 Finally, each contracted practitioner retains the to Sanford Health Plan, the claim will be denied. right to inquire about their credentialing application status. Contact a representative of the Provider Please note: Sanford Health Plan may be notified Relations Team. by NDDHS that a member has lost eligibility retroactively. When this happens, federal If there are new practitioners added to existing regulations require Sanford Health Plan, as the participating facility/groups, Sanford Health Plan MCO, to recoup payments made on an individual requires the new practitioner complete a Provider determined by the state of ND to be ineligible for Credentialing Application. Our Credentialing coverage. Application can be found here. Contact the Provider Relations Team at (800) 601-5086 if you have 4.7.4 Medical Record Standards questions. Sanford Health Plan ensures that each provider The following policy(s) are referenced in this section furnishing services to members maintains a and are available for review under “Resources” at medical record in accordance with professional, sanfordhealthplan.com/providerlogin. State, NCQA and CMS standards as well as standards for the availability of medical records • Practitioner Credentialing Policy (PR-06). appropriate to the practice site. Contracted practitioners/providers are required to maintain 4.7.2 Refusing to Treat a Sanford Health Plan a medical record on each individual member for a Member minimum of ten years from the actual visit date of service or resident care. Providers have the right to refuse to provide services to a Sanford Health Plan member. Records of minors shall be retained until the minor Providers are not to differentiate or discriminate reaches the age of majority plus an additional two in the treatment of Members or in the quality or years, but no less than ten years from the actual timeliness of services delivered to Members on the visit date of service or resident care. Medical basis of race, ethnicity, sex, age, religion, marital records are reviewed by our Care Management status, sexual orientation, place of residence, Team at a sample of clinics at least once per national origin, health status, genetic information, calendar year. Medical record review is conducted in lawful occupation, source of payment, credit history, conjunction with the HEDIS data collection process. frequency of utilization of services or any other The Care Management Team will complete the basis prohibited by law. While this is a very rare medical record review. event, it is required that the provider office contact the Care Management Team at (888) 315-0884 as Medical records may be requested by Sanford soon as possible so we can assist the member in Health Plan in connection with utilization or quality transitioning to a new provider. improvement activities, or may be requested as verification to support a claim; well documented 4.7.3 Member Eligibility Verification medical records facilitate communication, coordination and continuity of care; and they Each provider is responsible for ensuring that a promote the efficiency and effectiveness of member is eligible for coverage when services are treatment. rendered. Member eligibility can be determined by logging on to your secure online provider account. If A medical record is defined as patient identifiable you don’t have an account, see the Online Resources information within the patient’s medical file as section of this manual. In addition, our Customer documented by the attending physician or other Service Team can also assist you with member medical professional and which is customarily eligibility status questions. They are available from held by the attending physician or hospital. These 8 a.m. to 5 p.m. Monday through Friday at (800) medical records should reflect all services provided 752-5863. If the provider provides services to a by the practitioner including, but not limited to, all patient not eligible for coverage and remits a claim ancillary services and diagnostic tests ordered and 41 all diagnostic and therapeutic services for which the Sanford Health Plan monitors member complaints member was referred by a practitioner (i.e., home about office site quality. If Sanford Health Plan health nursing reports, specialty physician reports, has received three or more complaints within a hospital discharge reports, physical therapy six month period, a Provider Relations Specialist reports, etc.). will conduct an onsite visit within 60 days of the third complaint. The onsite visit will consist of a Medical records are to be maintained in a manner assessment of the physical appearance of the clinic, that is accurate, up-to-date, detailed and organized the physical accessibility and adequacy of waiting and permits effective and confidential patient care and patient exam rooms, adequacy of medical and quality review. Documentation of items from record keeping, as well as identification of any the ”Standards and Performance Goals for the other deficiencies. If deficiencies are detected, the Medical Record” demonstrates that medical records practitioner’s office will be asked to implement an are in conformity with good professional medical improvement plan. Sanford Health Plan will conduct practice and appropriate health management. The additional on site visits every six months until the organization and filing of information in the medical deficiency has been corrected. record is at the discretion of the participating provider. The Plan’s documentation standards for Sanford Health Plan will take into consideration medical record review include 17 components. the severity of the complaint and if we feel it is However, there are only 11 critical elements necessary, we reserve the right to conduct an onsite required in the medical record to demonstrate visit at any time regardless if an office has incurred good professional medical practice and appropriate a complaint. health management. Periodic medical record documentation reviews will be completed in The following policy(s) are referenced in this section conjunction with HEDIS medical record reviews. and are available for review under “Resources” at sanfordhealthplan.com/providerlogin. The following policy(s) are referenced in this section and are available for review under • Practitioner Office Site Quality Policy (PR-09). “Provider Resources” at sanfordhealthplan.com/ providerlogin. 4.7.6 Cultural and Linguistic Competency

• Medical Record (MM-24) Sanford Health Plan is committed to embracing the rich diversity of people we serve and believes 4.7.5 Practitioner Office Site Quality in providing high-quality services to culturally, linguistically and ethnically diverse population, Sanford Health Plan has established standards as well as those with physical, mental, visual and for office-site criteria and medical record-keeping hearing impairment. To be Cultural and Linguistic practices to ensure the quality, safety and Competent, means that Providers meet the unique, accessibility of office sites where care is delivered diverse needs of members, values & diversity to Sanford Health Plan members. The office site within the organization, and identifies members standards are as follows: with distinct needs in establishing access to care and support. Providers shall recognize and ensure 1. Physical Accessibility members receive equitable and effective treatment 2. Physical Appearance in an understandable and respectful manner, 3. Adequacy of Waiting and Examining Room recognizing individual spoken language(s), gender Space and orientation, and the role culture plays in a 4. Adequacy of medical treatment record keeping member’s health and well-being. paper based medical records 5. Electronic Medical Records Cultural competency is a set of congruent behaviors, attitudes and policies that enable

42 effective work and communication cross-cultural • Access to skilled interpreters to translate in situation. The awareness of culture is the ability non-English languages including American to recognize the cultural factors, norms, values, Sign Language. communications patterns/types, socio-economic • Obtain Cultural Competency Training including status and world views that shape personal and the review of materials on the Sanford Health professional behaviors. Culturally and Linguistic Plan Provider Portal and/or Newsletters. Appropriate services (CLAS) are health care services respectful of, and responsive to, cultural 4.8 Primary Care Responsibilities and linguistic needs. As a Primary Care Physician contracting with the The delivery of culturally competent health care Plan, the Physician shall provide the following and services requires health care Providers and services to Members in accordance with applicable their staff to integrate and transform skills, service Plan Health Maintenance Contracts: approach, techniques and marketing materials to match population culture and increase the quality 1. The Physician may have the primary and appropriateness of health care services and responsibility for arranging and coordinating outcomes. the overall health care of members who select the Physician as their Primary Care Physician. The objectives of Cultural Competency are to: This includes appropriate referral to specialist • Identify and accommodate those with physical Physicians and Providers under contract with and mental disabilities the Plan, arranging for the care and treatment • Identify Members who have potential cultural of such Member by hospitals, skilled nursing or linguistic barriers for which alternative facilities and other health care providers who communication methods are needed are Participating Providers, and managing and • Utilize culturally sensitive and appropriate coordinating the performance of administrative educational materials based on the Member’s functions relating to the delivery of health race, ethnicity and primary language spoken services to such Members in accordance with (including American Sign Language). this Agreement. • Make resources available to meet the unique language barriers and communication barriers 2. Routine office visits (including after-hours existing in the population office visits which can be arranged with other • Provide education to associates/staff on the Plan Physicians and with Plan approval) value of cultural and linguistic awareness and related services of the Physician and and differences in the organization and the other health care providers received in the populations served Physician’s office, including evaluation, • Decrease health care disparities in the diagnosis and treatment of illness minority populations served and understand and injury. how socio-economics status impacts care 3. Visits and examinations, including consultation Sanford Health Plan expects Providers to: time and time for personal attendance with the • Have written materials available for Members Member, during a confinement in a hospital, in large print format and certain non-English skilled nursing facility or extended care facility. languages, prevalent in SHP’s service areas • Provide ADA accessible offices, exam tables 4. Adult immunizations in accordance with and equipment accepted medical practice or Plan policies and • Telephone system adaptations for Members protocols. needing the TTY/TDD lines for hearing im- paired services and other auxiliary impairment 5. Administration of injections, including services injectables for which a separate charge is not routinely made.

43 6. Well-child care from birth for pediatric Members assigned to Physician. 18. Primary care physicians (PCP) have agreed to be available to members twenty-four (24) 7. Periodic health appraisal examinations. hours a day, seven days a week for urgent care. Members should call during normal 8. Eye and ear examinations for Members to office hours for routine situations, and only call determine the need for vision or hearing after hours in emergency or urgent situations. correction. Members who leave messages should receive a return call within thirty (30) minutes, or as soon 9. Diagnosis of alcoholism or drug abuse and as possible. appropriate referral to medical or non-medical ancillary services, but not the cost of such 4.9 Access Standards referral services. 4.9.1 Primary Care Physician 10. Routine office diagnostic testing, including chest x-rays, electrocardiograms, serum Through the contract and credentialing process, chemistries, throat cultures and urine cultures Primary Care Physicians (PCP) have agreed that and urinalysis, including interpretation; and urgent care services will be available to members interpretation of testing performed outside the 24 hours a day, seven days a week. Members Primary Care Physician’s office. should call during normal office hours for routine situations, and only call after hours for emergency 11. Miscellaneous supplies related to treatment or urgent care. Members leaving a message with in Primary Care Physician’s office, including the answering service of the PCP or the doctor on gauze, tape, Band-Aids, and other routine call should receive a call back within 30 minutes medical supplies. or as soon as possible. The following policy(s) are referenced in this section and are available for 12. Physician visits to the Member’s home or office review under “Resources” at sanfordhealthplan. when the nature of the illness dictates, com/providerlogin. as determined by the Primary Physician. • Provider Access and Availability Standards 13. Patient health education services and referral Policy (MM-50) as appropriate, including informational and personal health patterns, appropriate use of 4.9.2 Emergency Services health care services, family planning, adoption, and other educational and referral services, but In an emergency, members are encouraged to not the cost of such referral services. proceed to the nearest participating emergency facility. If the emergency condition is such 14. Telephone consultations with other Physicians that a member cannot go safely to the nearest and Members. participating emergency facility, then members should seek care at the nearest emergency facility. 15. Other primary care services defined by normal The member or a designated relative or friend practice patterns for Primary Care Physicians must notify the Plan and the member’s Primary in the Plan’s service areas required by the Plan. Care Physician (if applicable) as soon as reasonably 16. Such minor surgical procedures as the possible and no later than 48 hours after physically Physician ordinarily provides during the course or mentally able to do so. of his/her practice to his/her patient population on a fee for service or indemnity basis. Sanford Health Plan covers emergency services necessary to screen and stabilize members without 17. The list of provided services does not include precertification in cases where a prudent layperson, those services ordinarily provided as a specialty acting reasonably, believed that an emergency service in consultation. medical condition existed. The coverage shall be at 44 the same benefit level as if the service or treatment 4.9.4 Ambulance Service had been rendered by a Participating Provider. The Plan covers local ambulance services for the The Health Plan also covers emergency services if following: an authorized representative, acting for the Plan, has authorized the provision of emergency services. • Emergency transfer to a hospital or between hospitals. 4.9.3 Urgent Care Situations • Planned transfer to a hospital or between hospitals. An urgent care situation is a degree of illness or • Transfer from a hospital to a nursing facility. injury which is less severe than an emergency condition, but requires prompt medical attention Planned transfer to a hospital or between hospitals within 24 hours, such as stitches for a cut finger. If and transfers from a hospital to a skilled nursing an urgent care situation occurs, members should facility will only be covered when determined by contact their Primary Care Physician (if applicable) the Plan to be medically necessary either before or the nearest participating provider, urgent care or or after the ambulance is used. Prior authorization after hours clinic. is required for non-emergent ambulance services. The Plan does not cover charges for an ambulance If a member is admitted to the hospital, the member when used as transportation to a doctor’s office for or a designated relative or friend must notify the an appointment. Plan and the member’s Primary Care Physician (if applicable) as soon as reasonably possible and no 4.9.5 Out of Area Services later than 48 hours after physically and mentally able to do so. If an emergency occurs when traveling outside of the Plan’s service area, members should go to the If a member is admitted to a non-participating nearest emergency facility to receive care. The facility, the Plan will contact the admitting physician member or a designated relative or friend must to determine medical necessity and a plan for notify the Plan and the member’s Primary Care treatment. With respect to care obtained from a Physician (if one has been selected) as soon as non-participating provider within the Plan’s service reasonably possible and no later than 48 hours after area, the Plan shall cover emergency services physically and mentally able to do so. necessary to screen and stabilize a covered person. This may not require prior authorization if a prudent In-network coverage will be provided for emergency layperson would have reasonably believed that use conditions outside of the service area if the member of a Participating Provider would result in a delay is traveling outside the service area but not if the that would worsen the emergency, or if a provision member has traveled outside the service area for of federal, state, or local law requires the use of a the purpose of receiving such treatment. specific provider. The coverage shall be at the same benefit level as if the service or treatment had been If an urgent care situation occurs when traveling rendered by a Participating Provider. outside of the Plan’s service area, members should contact their primary care physician immediately, if one has been selected, and follow his or her instructions. If a primary care physician has not been selected, the member should contact the Plan and follow the Plan’s instructions.

In-network coverage will be provided for urgent care situations outside the service area but not if the member has traveled outside the service area for the purpose of receiving such treatment.

45 Out-of-network coverage will be provided for 4.9.8 Notification of Provider Network non-emergency medical care or non-urgent care Changes situations when traveling outside the Plan’s service area. Sanford Health Plan performs bi-annual surveys using a random sampling of our provider network to 4.9.6 Treatment of Family Members verify the accuracy of information displayed on our provider directory. Sanford Health Plan takes the position this it is not appropriate for a provider to provide health care If there are changes to the provider network, services to immediate family members, including Sanford Health Plan will notify its members in a any person normally residing in the Member’s home. timely manner. Members have access to the online There are however exceptions: This exclusion does provider directory, 24 hours a day, seven days not apply in those areas in which the immediate per week via their secure member accounts or at family member is the only Provider in the area. If the sanfordhealthplan.com. All providers who have immediate family member is the only Participating agreed to participate with the Plan shall be included Provider in the area, the member has the following in the directory for the duration of their contract. options: When a provider terminates his or her contract, a • The Member may be treated by that Provider if letter is sent to each member who has incurred a acting within the scope of their practice. service from that provider within the last 12 months. • The Member may also go to a Non-Participating The letter will inform the member that the provider Provider and receive In-Network coverage with is leaving our network as of a specified date. an approved prior authorization. If you have changes affecting your clinic, notify us as soon as possible. The following are the types of If the immediate family member is not the only changes that must be reported: Participating Provider in the area, the Member must go to another Participating Provider in order to • New address (billing and/or office) receive coverage at the in-Network level. • New telephone number • Additional office location Claims denied for treatment of family members • Provider leaves practice will deny with the following code: EX40-Charges • New ownership of practice for treating self/family members are ineligible • New Tax Identification Number • Accepting new patients 4.9.7 Provider Terminations • Change in liability coverage • Practice limitations (change in licensure, loss of As stated in our contract(s), all provider(practitioner, DEA certificate, etc.) organization, and hospital) voluntary terminations • New providers added to a practice must be made in writing to Sanford Health Plan • Change in Medicare or Medicaid Status 60 days prior to the effective termination date. For All written notices should be clear and legible. Minnesota practitioners or facilities, you must give This will ensure accuracy and allow for changes Sanford Health Plan 120 day notice. to be completed in a timely manner. A Provider Information Update/Change Form is also available Involuntary terminations will be sent to the provider online to submit changes. You can also send us via letter from Sanford Health Plan 60 days prior to your changes on your letterhead and fax to (605) the effective termination date. 328-7224 or you may mail the information to the following address: Attn: Provider Relations Sanford Health Plan PO Box 91110 Sioux Falls, SD 57109-1110 46 Quality Improvement & Medical Management

5.1 Quality Improvement Program • Diabetes • Healthy Heart (hypertension) Sanford Health Plan and its participating • Heart Failure practitioners and providers are fully supported 2. Quality improvement activities by a sophisticated ambulatory and institutional 3. HEDIS® and CAHPS® Report quality management program. The organized 4. Clinical resources and tools which include but method for monitoring, evaluating, and improving are not limited to: the quality, safety and appropriateness of health • Clinical Practice Guidelines care services, including behavioral health care • Preventive Health Guidelines which encompasses mental health and substance • Quick Reference Behavioral Health Cards use disorders, to members through related • Immunization Schedules activities and studies is known as the Quality Improvement (QI) Program. The Plan monitors its The following policy(s) are referenced in this use of resources in order to ensure appropriate section and are available for review under distribution of assets throughout the entire system “Resources” at sanfordhealthplan.com/ and provides accountability for the quality of health providerlogin. care delivery and service. This is accomplished through the commitment of the Board of Directors, • Quality Improvement Program (MM-56). the Physician Quality and the Health Plan Quality Improvement Committees. 5.1.1 Complex Case Management Referral Guide Providers are encouraged to view the programs offered to members at the home screen of Complex case management (CCM) is the sanfordhealthplan.com/providerlogin. coordination of care and services provided to members who have experienced a critical medical 1. Health Management programs provide event or diagnosis that requires the extensive use members with disease management services. of resources and who may need help navigating We contact our members by phone, through the health care system to facilitate appropriate educational tools and with support. By doing delivery of care and services. The goal of complex so, members are equipped to control and case management is to assist members to understand their condition, thereby lessening regain optimum health or improved functional complications. Learn more in our “clinical capability by monitoring their care. We can also toolbox.” The programs offered are: ensure member care follows evidence based • Asthma clinical standards so there are no gaps in care, • Coronary Artery Disease and to ensure members are receiving health

47 care in a cost-effective manner. This plan also personnel, given a standard of desirable care. involves the comprehensive assessment of the This process reviews the following items to member’s condition; determination of available determine if the treatment, as prescribed, is benefits and resources; and development and appropriate: implementation of a case management plan with performance goals, monitoring and follow-up. 1. Medical necessity of the treatment 2. Setting for the treatment Sanford Health Plan’s Complex Case Management 3. Types and intensity of resources to be used in Program is available at no cost to qualifying the treatment Sanford Health Plan members and their families. 4. Time frame and duration of the treatment Concentrating on catastrophic or chronic cases, case managers consult and manage the following: Our Utilization Management Team is available between the hours of 8 a.m. and 5 p.m., CST, • Multiple chronic illnesses (e.g., diabetes and Monday through Friday (excluding holidays). cardiovascular problems) and/or chronic After hours, members and providers may leave illnesses resulting in high utilization a message on the confidential voice mail and a • Individuals with physical or developmental representative will return your call the following disabilities, serious and persistent mental business day, no later than 24 hours after the illness, or severe injuries initial inquiry call. • High risk or complicated medical conditions Member questions per line of business: (e.g., transplants, spinal cord injuries, cancer) • Multiple readmissions NDPERS – 1-888-315-0885 • Individuals identified from predictive modeling ND Medicaid Expansion – 1-855-276-7215 reports based on high cost, likelihood of All other – 1-800-805-7938 hospitalization, projected total risk, etc. 5.2.1 Utilization Review Process *HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). The purpose of Utilization Review is to establish requirements and standards of operation for the *CAHPS® is a registered trademark of the Agency certification of medical utilization. The criteria for Healthcare Research and Quality (AHRQ). for medical services used by the Utilization Management Department shall be made available, If you would like more information or need to upon request, to Participating Physicians. Clinical refer a qualified Sanford Health Plan Member for review criteria may be developed based on the program, please contact Care Management Milliman Care Guidelines (MCG), eviti, literature at (888) 315-0884 or by email at quality@ review, specialty society standards of care, sanfordhealth.org. For Sanford EPIC users, you Durable Medical Equipment criteria, Medicare can also use in-basket messaging. If a Health Plan guidelines, and health plan benefit interpretation. case manager is currently following a member, Local medical review policies will be utilized for the case manager will be listed on the patient decisions regarding Medicare coverage. care team in One Chart. If you are unable to determine the assigned case manager, you can Sanford Health Plan utlizes MCG guidelines for send an in-basket message to SHP CRM CT Case appropriateness of care. UM staff reviews all Management. cases and can refer to the VP, Medical Officer or Behavioral Health Practitioner where medical 5.2 Medical Management Program necessity and/or criteria are not met. UM staff cannot make denial decisions in these cases, but The Medical Management Program (also referred can make authorization decisions based on MCG to as Utilization Management or UM) is defined as guidelines, procedures and benefit coverage an organized method for monitoring and evaluating guidelines. UM staff base their decisions on the course of treatment given by all health care accepted review criteria, medical record review, 48 and/or consultations with appropriate physicians. How to Authorize:

5.2.2 New Medical Service or Product Prior authorizations for health care services Consideration can be obtained by contacting the Utilization Management Department online, by phone or fax: Provider may submit the “Request for Benefit NOTE: Oncology treatment and services must Consideration” form found online at be entered and authorized through sanfordhealthplan.com/providers where there is a eviti|Connect online at eviti.com). new medical service or product you want Sanford • Online: Select “Authorizations” in your Health Plan to consider for benefit coverage. The secure mySanfordHealthPlan account at form must be completed prior to claim submission sanfordhealthplan.com/providerlogin. of the new product or service for which the Click on on either “Submit a Pharmacy benefit coverage consideration is being reviewed. Preauthorization” or “Submit a Medical Completing this form does not guarantee coverage Preauthorization” depending on your request. of benefits. Once you complete the required information click “Submit.” 5.2.3 Prior Authorizations • Phone: Call the appropriate number below and follow the menu prompts. Team members are Prior authorization (certification or available to take your calls from 8 a.m. to 5 precertification) is the urgent or non-urgent p.m. CST, Monday through Friday. After hours authorization of a requested service prior to you may leave a message on the confidential receiving the service. The approval for prior voice mail and someone will return your call authorization is based on appropriateness of the following business day. care and service and existence of coverage. - North Dakota Medicaid Expansion members Points to remember: (855) 276-7214 - Commercial, Self-funded or Sanford Group 1. Members are ultimately responsible for Health members (800) 805-7938 obtaining prior authorization in order to - NDPERS members (888) 315-0885 (8 a.m. to receive in-network coverage. However, 5:30 p.m. CST Monday-Friday) information provided by your office will also • Fax: The prior authorization form and satisfy this requirement. supporting documentation can be faxed to 2. All requests for certification are to be made (605) 328-6813. by the member or their practitioner’s office at least three working days prior to the The date of receipt for non-urgent requests scheduled admission or requested service. received outside of normal business hours will If health care services need to be provided be the next business day. The date of receipt for within less than three working days, contact urgent requests will be the actual date of receipt, the Utilization Management Department to whether or not it is during normal business hours. request an expedited review. 3. All referrals to non-participating providers (at the recommendation of a participating provider) require prior authorization. 4. A list of services that require prior authorization can be found online at sanfordhealthplan.com/providerlogin.

49 The following services require prior authorization: Procedure or Service Coverage Description Admission Include: • Inpatient Medical, Surgical, Behavioral Health or Chemical Dependency • Inpatient Rehabilitation Admissions • Long Term Acute Care (LTAC) • Residential Treatment • Skilled Nursing Facility • Swing Bed Includes the following: Ambulance Services • Air Ambulance Services • Non-emergent transportation Clinical Trials All clinical trials 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 Durable Medical Equipment • 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 and Hospice Services include: • Home Health Services Home Health/Hospice Services • Home Infusion (IV) Services • Hospice Services Implants and Stimulators include: • Bone Growth (external) • Cochlear Implant (Device and Procedure) • Deep Brain Stimulation Implants/Stimulators • Gastric Stimulator • Spinal Cord Stimulator (Device and Procedure) • Vagus Nerve Stimulator Includes all chemotherapy and radiation therapy as part of an oncology treatment plan Oncology Services and Treatment NOTE: Oncology treatment and services must be authorized online at connect.eviti.com Outpatient Services include but is not limited to: • Applied Behavioral Analysis (ABA) • Biofeedback • Botox • Brachytherapy • Chelation Therapy • Dental Anesthesia • Genetic Testing Outpatient Services • Home Sleep Study • Hyperbaric Oxygen Therapy • Infertility Treatment • Medical Nutrition • Neuromuscular Electrical Stimulation • Orthodontia • Photodynamic Therapy • Platelet Rich Plasma (PRP) • Varicose Vein Treatment 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 Outpatient Surgery • Intrathecal Pain Pump • Mammoplasty • Orthognathic 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 Continued on next page 50 5.2.4 Sanford Health Plan Referral Center Additional Notes The Referral Center assists providers in finding Simplicity and TRUE members only: The services listed above still apply to Simplicity and TRUE members. the right specialist or medical resources for These plans offer pediatric dental coverage. Therefore, the following procedures require prior-authorization: your Sanford Health Plan patient. The center will • Medically-Necessary Dental Implants for Children Age 0-18 Years** have access to all Sanford Health Plan network • Medically-Necessary Orthodontics for Children Age 0-18 Years **Other periodontic and endodontic procedures do not require prior specialists, contact information, services and authorization procedures provided and their location(s)/ For Heart of America commercial members only: outreaches within our service area. Our staff will The list of services requiring prior authorization from above still applies. The one addition is: give personal attention to each inquiry by gathering • Any services rendered by the Altru Health System need prior details about the patient and will give you available authorization because Altru providers and facilities are considered Out of Network. options.

For Heart of America Medicare Cost members: The list of services requiring prior authorization from pages 1 and 2 still Who can use? applies. The one addition is: Any services rendered by Trinity Health need prior authorization because Providers and nursing staff can call the referral Trinity Health providers and facilities are considered Out of Network. center and identify the type of specialty their North Dakota Medicaid Expansion plan members only: patient needs. These plans offer pediatric dental coverage. The following procedures require prior-authorization: • Medically-Necessary Dental Implants for Members Age 19-20 How do you contact the Referral Center? Years** • Medically-Necessary Orthodontics for Members Age 19-20 Years The Referral Center will be available for **Other periodontic and endodontic procedures do not require consultation by phone or email. prior authorization. Call 844-836-1616 or (605) 333-1616, or email For complete the comprehensive listing of prior authorization information, please refer to the member plan document. Refer [email protected]. to the Sanford Health Plan pharmacy handbook and formulary for medications requiring prior authorization. Staff will be available Monday – Friday, 7:30am-6:30pm CST. Additional Medical Management Program Information 5.2.5 Coordinated Services Program (CSP) You may also find the following information in mySanfordHealthPlan at sanfordhealthplan.com/ Sanford Health Plan administers a CSP as allowed providerlogin under 42 CFR § 431.54 specifically for the ND Medicaid Expansion population. The CSP is in 1. The complete Medical Management Program place to restrict a Member (who meets specific Description, including further operational criteria) in to a pharmacy and/or a primary care details, prior authorization and denial and physician. Case Managers work with the member appeal procedures are available. in coordinating healthcare services to match 2. UM criteria is available to practitioners and their medical needs, improve quality of care by providers by phone or mail. A physician building a patient-doctor relationship, and to reviewer is made available by phone to any promote proper use of health care services and practitioner to discuss determinations based medications. on medical appropriateness. Members in this program will have one CSP The following policy(s) are referenced in this doctor and one CSP pharmacy. Sanford Health section and are available for review under Plan selects the CSP doctor and pharmacy based “Resources” at sanfordhealthplan.com/ on past utilization. Members do have the right to providerlogin. appeal their participation in the program and have 30 days from the time they are notified to request a • Utilization Management Program policy change in their CSP doctor or pharmacy. (MM-49). Providers chosen as a CSP doctor will be notified that they are the primary contact for medical needs, with the exception of emergencies. CSP

51 members will be required to get all prescriptions 2. Listed in the Plan Formulary, unless from the assigned CSP pharmacy. Case managers certification is given by the Plan; will monitor and review members on an annual 3. Provided by a Participating Pharmacy except basis for continuation in the CSP program. You will in the event of a medical emergency. If the be notified when a member is no longer required prescription is obtained at a Non-Participating to be in the CSP program. CSP doctors will Pharmacy, the member is responsible for the agree to: prescription drug • Manage all medical care for the member cost in full; • Educate the member on the appropriate use of 4. Approved by the Federal Food and Drug services Administration for use in the United States. • Provide referrals to specialty physicians • Be available telephonically or ensure a 5.2.7 Sanford Health Plan Formulary provider of comparable specialty is available 24 hours a day, 7 days a week for urgent or Sanford Health Plan’s Formulary is a list of emergent medical situations medications that are the most effective for • Manage acute and/or chronic pain through a the treatment of disease and maintenance variety of of health according to the clinical judgment services or treatment options of the practitioners, pharmacists, and other • Approve or deny medications prescribed by health care professionals who helped develop other providers when contacted by the specific the Plan’s Formulary. Sanford Health Plan CSP pharmacy realizes that prescription drugs are a significant • Work with pharmacists and other specialty portion of health care costs. Our team of health physicians to share pertinent information care professionals works hard to develop the regarding the member. best formulary for our members. They review the formulary each year to ensure that the 5.2.6 Pharmacy Management and medications included on the formulary are Formulary Program Information the most effective for the treatment of disease and maintenance of the health of our members. One of Sanford Health Plan’s missions is to If changes are made to the formulary, members improve the health status of members by who are directly impacted receive a letter from developing a model of quality patient care utilizing Sanford Health Plan with notification of the cost-effective medications as established by sound formulary change. clinical evidenced based medicine. We contract with Express Scripts Inc. as our Pharmacy Resources: Benefits Manager to promote optimal therapeutic 1. Sanford Health Plan Formulary, including use of pharmaceuticals. ESI currently supports drug prior authorization, step therapy, the Plan’s Formulary for oral and injectable generic substitution requirements, etc. medications. The Pharmacy Management can be found online and within your secure Department can be reached from provider account. 8 a.m. to 5 p.m., CT, Monday through Friday at one 2. Express Scripts website: express-scripts.com of the following numbers: If you feel that Sanford Health Plan should • Commercial, TPA and Sanford Health Plan consider coverage of a medication based on Heart of America products - (855) 305-5062 medical necessity for medications not on the • North Dakota Medicaid Expansion – Formulary, please follow the Exception to (855) 263-3547 Formulary Process in your Policy or contact • NDPERS – (877) 658-9194 Pharmacy Management at (605) 312-2756 or(855) 305-5062. For NDPERS members, To be covered by the Plan, drugs must be: call (877) 658-9194 and for ND Medicaid members, 1. Prescribed by a licensed health care call (855) 263-3547. professional within the scope of his or her practice; 52 Filing Claims

6.1 Member Eligibility and Benefit accessing the ND Health Enterprise MMIS portal, Verification or by contacting the ND Automated Voice Response System at 1-877-328-7098. Sanford Health Plan offers two convenient options to verify eligibility and benefits: online or by phone. For members identified as having North Dakota Contact our Customer Service Department: traditional Medicaid coverage, you may submit the claims using one of the following options: Phone: (800) 752-5863 or (605) 328-6800 from 8 a.m. to 5 p.m. CST, Monday through Friday. 1. Electronic Claim Submission – utilizing the Online: sanfordhealthplan.com/providerlogin. North Dakota MMIS Web Portal found here. If needing to submit the remittance advice, Each provider’s office is responsible for ensuring indicate that there is a claims attachment that a member is eligible for coverage when and fax in documentation using the “MMIS services are rendered or prior to time of service. Attachment Cover Sheet” (SFN 177) form If a provider’s office fails to check eligibility for which can be found here. a member who is not eligible for coverage and submits a claim to Sanford Health Plan, the claim 2. Paper Claim Submission – attach remittance will be denied. advice to claim if needing to submit

6.1.1 North Dakota Medicaid Expansion If any of the claims will not meet the North Dakota Eligibility Adjustments Medicaid requirements for timely filing, these claims must be submitted with the remittance Sanford Health Plan processes eligibility files advice you received from us showing the date the received from North Dakota Department of claim was re-adjudicated or denied for Medicaid Human Services (NDDHS) for benefits and claims Expansion coverage by Sanford Health Plan. adjudication. Please note: Sanford Health Plan may be notified by NDDHS that a member has lost 6.2 Claims Submission eligibility retroactively. When there is a change in eligibility, Sanford Health Plan will process Sanford Health Plan participating providers are any overpayments by taking deductions on future required to submit claims on members’ behalf. claims. Claim adjustments will appear on the next Claims should be submitted to Sanford Health Plan EOP for any effected claims. electronically using Payor ID 91184. We encourage you to transmit claims electronically for faster Providers are able to verify member’s eligibility reimbursement and increased efficiency (Please with North Dakota traditional Medicaid by see Provider EDI Resources in the provider manual

53 or on the website for more information). Accepted • Use a standard claim form (individually claims forms are a standard CMS, UB or ADA created forms have a tendency to not line up claim. Submitting these forms with complete and correctly, prohibiting the claim from scanning accurate information ensures timely processing of cleanly). your claim. All claims should be submitted using • The billing, servicing and/or rendering current coding and within 180 days, or as defined in provider’s your contract even if the member has not exceeded NPI must be included in the designated their deductible or copay amounts. locations for accurate matching within the scanning and 6.2.1 Paper Claims Submission claim system. • For a continued claim, please indicate If you do not wish to file claims electronically, “continued” in the appropriate box of the claim paper claims can be mailed to: form so the claims can be kept together and whole. Sanford Health Plan Claims Department • Do not place the total amount on each of the PO Box 91110 individual pages. Sioux Falls, SD 57109-1110 6.2.2 Corrected/Voided Claims Submission To improve our turnaround time and accuracy of paper claim processing, we use a scanning A corrected claim is defined as a re-submission of procedure using the Smart Data Solutions (SDS) a claim, such as changes to CPT codes, diagnosis system. It is important for you to know that the SDS codes or billed amounts. It is not a request to system uses optical character recognition (OCR). review the processing of a claim. If you need Therefore, when OCR is used, your provider name to submit a corrected claim due to an error or must match our records in order for the system change on an original submission, you can do so to correctly identify the “pay to” information. If a electronically or by paper. Corrected claims must mismatch occurs, or if the claim cannot be read, be received within 60 days of the date of initial you will receive a letter from SDS asking you for processing as indicated on the Explanation of the missing or illegible information. A prompt Payment. response will prevent further delay in processing your claim. Voided claims are defined as a claim needing to be recouped and no reprocessing is necessary. When sending paper claims, please follow these The entire claim must match the original, with guidelines: the exception of the claim frequency code and reference to the Sanford Health Plan original claim • Print on a laser printer number. • If a dot matrix printer must be used, make sure it is legible When submitting corrected or voided claims, do • Use Courier New 10 point font for clean not submit claims electronically and via paper at scanning. the same time. Medical records are not required • Use uppercase for optimal scanning. with the submission of a corrected claim and are • Ensure that clean character formation occurs only needed when specifically requested from us. when printing paper claims (i.e. one side of the letter/number is not lighter/darker than the Providers using Electronic Data Interchange (EDI) other side of the letter/ number). can submit professional and institutional corrected • Claim forms should be lined up properly claims. The corrected Claim needs to contain the • Do not place additional stamps on the claim adjusted coding to help us identify and process the such as received dates, sent dates, medical claim accurately. records attached, resubmission, etc. • Use an original claim form - not a copied claim Corrected claims filed electronically should be form. submitted with ALL service line items. 54 Enrollment Instructions, visit our website at • Enter Claim Frequency Type code (billing code) sanfordhealthplan.org/providers/edi-resources 7 for a replacement/correction, or 8 to void a prior claim, in the 2300 loop in the CLM*05. 6.4 Instructions for completing the • Enter the original claim number as processed CMS 1500 by Sanford Health Plan in the 2300 loop in the REF*F8*. Physicians and Allied Health Professionals should use the Center of Medicaid and Medicare Services Corrected or voided claims submitted by paper (CMS) form 1500 to bill for medical services. need to be clearly identified as “CORRECTED Please follow the link for detailed instructions on CLAIM” or “VOIDED CLAIM” at the top of the claim how to correctly fill out the CMS 1500 form. form. If you are correcting or voiding a UB-04 claim, use appropriate type of bill type of XXX7 or Mandatory or Field Description and Information XXX8 in box 4. Optional Type of insurance – check 1 Optional appropriate box. 6.3 Provider EDI Resources Insured’s ID Number – Enter the member’s 11 digit number as it 1a Required appears on their Sanford Health Sanford Health Plan provides a variety of EDI Plan ID card. resources for both professional and institutional Patient’s name- Enter the name of 2 Required claims to increase efficiency, track claim status, the member as it is on the ID card. Patient’s birth date and check box decrease errors, expedite cash flow, and reduce 3 Required for male or female. costs. Insured’s name- The name of the 4 If applicable policy holder 6.3.1 EDI Services Patient’s complete address and 5 Required phone number. • 837 Health Care Claim Transactions Electronic 6 Patient relationship to insured. If applicable Funds Transfer (EFT) 7 Insured’s address. Not required • 835 Health Care Claim Payment/Advice 8 Patient status. Not required Transactions Other health insurance coverage - Identify other group coverage for • 270/271 Real Time Transactions for Eligibility, 9 a-d accurate coordination of benefits. Not required If the patient has no other group Coverage, or Benefit Inquiry & Information coverage, enter NONE • 276/277 Real Time Transactions for Health Is patient’s condition related to 10 coverage for employment, auto or Not required Care Information Status Request and a-c other accident related claims? Response. Reserved for local use. Not required To review these forms, trading partner agreement 10 d Insured’s information – Name, and companion guides, click here. Call our EDI policy/group number, employer/ 11 a-b Not required department if you have questions when completing school name, insurance plan/ program name. the forms. For Medicare crossover claims, 11 c If applicable enter the Medicare Carrier Code. Is there another health benefit 6.3.2 EDI Enrollment 11 d Required plan? Check yes or no. Sanford Health Plan exchanges data with several 12 Patient’s signature and date. Not required vendors and clearinghouses. Trading Partners who 13 Insured signature. Not required The date of first symptom for want to exchange data electronically with Sanford 14 current illness, injury or last Required Health Plan will need to complete our Trading menstrual period for pregnancy. The date the same or a similar Partner Agreement. 15 Not required illness. Dates patient unable to work in 16 Not required current occupation. For further information or to download the 17 Name of referring physician. If applicable Trading Partner Agreement and our EFT

55 Mandatory or Mandatory or Field Description and Information Field Description and Information Optional Optional ID number of referring physician Federal Tax ID Number – Enter 17 a – enter state medical license If applicable 25 the Federal Tax ID Number for the Required number. billing provider. Enter referring provider’s NPI 26 Patient’s account number Optional 17 b If applicable number. 27 Accept assignment Not required Hospitalization dates related to 18 If applicable current services. 28 Total charges for services Required 19 If applicable 29 Amount paid If applicable Outside lab – check yes when Balance due – Enter the differ- diagnostic test was performed by 30 ence between the total charges If applicable 20 If applicable any entity other than the provider for services and the amount paid. billing the service. Signature of physician or supplier 31 Required Enter the patient’s diagnosis or including credentials. 21 condition. Use ICD-10 code and Required Service facility location informa- use the highest level of specificity. tion – Enter the name, address, 22 Medicaid resubmission code. 32 city, state and zip code of the Required location where the services were 23 Prior authorization number. If applicable rendered. Use this area for reporting NPI Number - Enter the NPI 24 If applicable supplemental information. 32 a number where the services were Required rendered. 24 a Dates of service Required 32 b Other ID number If applicable 24 b Enter code for place of service. Required Billing provider info and phone 24 c Emergency indicator If applicable number – Enter the provider 33 Required name, address, city, state, zip Procedures, service or supplies code and telephone number. – Enter the applicable CPT or 24 d Required HCPCS code(s) and modifiers in NPI number – enter the billing 33 a Required this section. provider’s NPI Diagnosis pointer – enter the 33 b Other ID number Required diagnosis code number from box 24 e Required 21 that applies to the procedure code in 24 d. Charges – Enter the charge in dollar amount format for each listed service. If the item is a 24 f Required taxable medical supply, include the applicable state and county sales tax. Days or Units – Enter the number of medical visits, procedures, 24 g Required units of service, oxygen volume etc. Do not leave blank. EPSDT Family Plan – Enter code 1 or 2 if the services rendered are related to family planning 24 h (FP). Enter code 3 if the services If applicable rendered are Child Health and Disability Prevention screening related. 24 i ID Qualifier - If applicable Rendering Provider ID#/NPI – 24 j Enter the rendering provider’s If applicable NPI number.

56 57 6.5 UB-04/CMS-1450 claim form and Field loca- instructions: Description Inpatient Outpatient tion UB-04 Commonly known as UB-04, the CMS-1450 form Required, if 13 Admission Hour Required is used by institutional providers to bill payors applicable including Sanford Health Plan. Examples of 14 Type of Admission/Visit Required Required institutional providers include and are not limited 15 Source of Admission Required Required

to the following: 16 Discharge Hour Required N/A

17 Patient Discharge Status Required Required • Hospital Required, if Required, if 18-28 Condition Codes • End Stage Renal Disease applicable applicable • Hospices 29 Accident State Situational Situational • Comprehensive Outpatient Rehabilitation 30 Future Use N/A N/A Facilities Occurrence Codes and Required, if Required, if 31-34 • Community Mental Health Centers Dates applicable applicable Occurrence Span Codes Required, if Required, if • Federally Qualified Health Centers 35-36 and Dates applicable applicable • Skilled Nursing Facilities • Home Health Agencies 37 Future Use N/A N/A Responsible Party Name Required, if Required, if 38 • Outpatient rehabilitations clinics and Address applicable applicable • Critical Access Hospitals Required, if Required, if 39-41 Value Codes and Amounts applicable applicable UB-04/CMS-1450 instructions: 42 Revenue Code Required Required Field 43 Revenue Code Description Required Required loca- Required, if Required, if Description Inpatient Outpatient NDC Code tion applicable applicable UB-04 Required, if Required, if 44 HCPCS/Rates Provider Name and applicable applicable 1 Required Required Address 45 Service Date N/A Required 2 Pay-to Name and Address Situational Situational 46 Units of Service Required Required 3a Patient Control Number Required Required Total Charges (By Rev. 47 Required Required 3b Medical Record Number Situational Situational Code) Required, if Required, if 4 Type of Bill Required Required 48 Non-Covered Charges applicable applicable 5 Federal Tax Number Required Required 49 Future Use N/A N/A 6 Statement Covers Period Required Required 50 Payer Identification (Name) Required Required 7 Future Use N/A N/A Health Plan Identification 51 Situational Situational 8a Patient ID Situational Situational Number

8b Patient Name Required Required Release of Info 52 Required Required Certification 9 Patient Address Required Required Assignment of Benefit 53 Required Required 10 Patient Birthdate Required Required Certification 11 Patient Sex Required Required Required, if Required, if 54 Prior Payments applicable applicable Required, if 12 Admission Date Required applicable 55 Estimated Amount Due Required Required

56 NPI Required Required

58 Field loca- Description Inpatient Outpatient tion UB-04

57 Other Provider IDs Optional Optional

58 Insured’s Name Required Required Patient’s Relation to the 59 Required Required Insured 60 Insured’s Unique ID Required Required

61 Insured Group Name Situational Situational

62 Insured Group Number Situational Situational Treatment Authorization Required, if Required, if 63 Codes applicable applicable 64 Document Control Number Situational Situational

65 Employer Name Situational Situational Diagnosis/Procedure Code Required, if Required, if 66 Qualifier applicable applicable Principal Diagnosis Code/ 67 Required Required Other Diagnosis Codes 68 Future Use N/A N/A Required, if 69 Admitting Diagnosis Code Required applicable Patient’s Reason for Visit 70 Situational Situational Code 71 PPS Code Situational Situational External Cause of Injury 72 Situational Situational Code 73 Future Use N/A N/A Principal Procedure Code/ Required, if Required, if 74 Date applicable applicable 75 Future Use N/A N/A Attending Name/ID-Qual- 76 Required Required ifier 1G 77 Operating ID Situational Situational

78-79 Other ID Situational Situational

80 Remarks Situational Situational

81 Code-Code Field/Qualifiers

*0-A0 N/A N/A

*A1-A4 Situational Situational

*A5-AB N/A N/A AC – Attachment Control Situational Situational Number AD-B0 N/A N/A

*B1-B2 Situational Situational

*B3 Required Required

59 ______

1 2 3a PAT. 4 TYPE CNTL # OF BILL b. MED. REC. # 6 STATEMENT COVERS PERIOD 7 5 FED. TAX NO. FROM THROUGH

8 PATIENT NAME a 9 PATIENT ADDRESS a

b b c d e ADMISSION CONDITION CODES 30 10 BIRTHDATE 11 SEX 16 DHR 17 STAT 29 ACDT 12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28 STATE

31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH

a a

b b

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES CODE AMOUNT CODE AMOUNT CODE AMOUNT a b c d

42 REV. CD. 43 DESCRIPTION 44 HCPCS / R ATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TO TAL CHARGES 48 NON-COVERED CHARGES 49

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22

23 PAGE OF CREATION DATE TOTALS 23 52 REL . 53 ASG. 50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI INFO BEN. A 57 A

B OTHER B

C PRV ID C

58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A A

B B

C C

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A

B B

C C

66 68 DX 67 A B C D E F G H I J K L M N O P Q 69 ADMIT 70 PATIENT 71 PPS 72 73 DX REASON DX a b c CODE ECI a b c 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 QUAL CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI LAST FIRST

c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE QUAL CODE DATE CODE DATE CODE DATE 77 OPERATING NPI LAST FIRST 81CC QUAL 80 REMARKS a 78 OTHER NPI b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. ™ National Uniform 60 NUBC Billing Committee 6.6 Claims Payment If the member fails to show their ID card at the time of service and you bill the wrong plan, then Claims must be submitted within the filing period the member may be responsible for payment of of 180 days from date of service or as defined the claim after the timely filing period has expired. in your contract. For inpatient services, timely Sanford Health Plan will only process claims filing begins from the date of discharge. Claims with this denial at your request. Both you and the submitted outside of the filing period will be Member will receive an EOP and Explanation of denied due to untimely filing. Charges denied for Benefits (EOB) showing this denial. At this point, untimely filing are not to be billed to the member, you accept responsibility for settling payment of but must be written off. If it was not reasonably the claim with the Member. possible to send a claim within the filing period, you must follow up appropriate documentation 6.6.1 Process for Refunds or within 60 days from the date of the denial shown on Returned Checks the Sanford Health Plan Explanation of Payment. For North Dakota Medicaid Expansion members, Sanford Health Plan processes overpayments by providers have 365 days from the date of service to taking deductions on future claims. You may return submit claims. the overpayment directly to Sanford Health Plan, We strive to reimburse providers for “clean” claims but it will only be accepted if the overpayment within 30 days of the receipt of the claim, and in has not already been offset by other claims. If the North Dakota 15 days of receipt of a clean claim. overpayment remains outstanding for more than Clean claims are those claims not requiring 90 days, our Finance Department will send you a additional information before processing. letter requesting payment.

We will respond within 60 days of receipt for If Sanford Health Plan has paid a claim in error, claims requiring additional information before you may return the check or write a separate processing (i.e. accident details, or other coverage check for the full amount paid in error. A copy of information). If you do not receive an Explanation the remittance advice, supporting documentation of Payment (EOP) from the Plan within the 60 days noting reason for the refund should be included from the claims filing date, it is advisable to check with the refund. the status through your secure provider account or by calling Customer Service. Refunds should be sent directly to the Finance Department at this address: No legal action may be brought to recover under this provision within 180 days after the claim Attn: Finance Department has been received as required by your provider Sanford Health Plan contract. No action to recover member expenses PO Box 91110 may be brought forth after four years from the Sioux Falls, SD 57109-1110 time the claim is processed.

61 6.7 Understanding Your Check Adjustment Report

The purpose of this report is to show you claim(s) affected by a check adjustment. This can be created through a negative balance, ad hoc adjustment, or a check amount not matching the remittance advice amount.

The following is a description of what you will find on the report and how to apply the funds to claims.

SANFORD HEALTH PLAN Check Adjustment Report *This adjustment report identifies all effected claims where there is a negative balance, ad hoc adjustment, or check amount not matching the remittance advice amount.* Negative Vendor Run Vendor Checking Check Check Claim Adjustment Refund Balance Name Number ID Account Number Date Amount Total Amount Amount

This section provides check information in referencing the EOP associated with the report. The EOP will arrive a few days after receiving this report. If you would like to view the EOP, log on to your secure account and search the EOP by check number.

Claim List Account Original Patient Name DOS Claim ID Claim Amount AP Date Vendor ID Number Claim

This section shows claims from the EOP and are affected by a check adjustment. If there are no claims listed, reference the EOP sent separately from this report. We have included patient name and your account number for your reference.

Negative Balance Carryovers Adjustment Description Claim ID Amount AP Date Comment Line

This section shows the amount that was applied from a previously paid and adjusted

Negative Balance Carryovers

Claim Amount Claim amount equals the total net payable of the claims on the EOP. Negative Balance Amount Negative Balance Amount equals the amount applied to the check. Refunds Amount equals refunds that have been processed. Refunds Amount Ad Hoc Amount equals a payment made to make previous checks whole. Ad Hoc Amount This amount should be applied to those claims. Check amount equals the check/EFT total you Check Amount received or will receive shortly.

Negative Balance Carryovers Item Patient Account Claim Reversed Check DOS Claim ID AP Date Check Date Description Name Number Amount Claim ID Number

This section will show which claim(s) have been adjusted and payment amount. These funds should be applied to the claims associated with the EOP in order to make the check whole.

62 6.8 How to Read Your patient pays the provider 14. Withhold Amount: A type of Explanation of Payment for covered services before Sanford Health Plan begins risk- arrangement entered 1. Need more information: to pay. into by providers. The term Contact information • Copay: The amount refers to a percentage of a for Sanford Health Plan patient owes the provider set dollar amount deducted at the time of service and is from providers’ payment 2. Check / EFT #: Payment not part of the deductible or amount. It is set aside in information identifying the out-of-pocket maximum. risk pools and may or may Tax ID the payment was •Coinsurance: The patient’s not be returned depending made under, the payment share of the cost of covered on specific predetermined date and the check or EFT services. factors or events. transaction number. 12. TPP: A Third-Party 15. Explanation: Codes used to 3. Service Date(s): Actual Payer is any institution explain any claim financial date the health service was or company, outside of adjustments, such as provided. Sanford Health Plan, which denials, reductions or 4. Diag # / DRG #: ICD-10 provides reimbursement increases in payment. Diagnosis code or to providers for services 16. Post Date: The date diagnosis-related group rendered to patients. payment was made by code. 13. Payment Amount: The Sanford Health Plan to the 5. Proc #: Type of services amount Sanford Health provider. provided. Plan paid to the provider 6. Days / Units: Quantity of for this claim. specific service rendered. 7. Charged Amount: The total amount billed by the provider of services. 8. Amount Not Covered: Amount not eligible for payment from Sanford Health Plan. 9. Discount Amount: The amount the primary payer deducted from the charged amount based on contractual agreement between the provider and Sanford Health Plan. 10. Allowed Amount: The pre-negotiated rate paid to In-Network providers for covered services. For Out-of Network providers it is the Usual, Customary and Reasonable cost. 11. Ded./CoPay./Colns.: • Deductible: The amount

63 6.9 Provider Reimbursement 6.9.2 Non-Participating Provider Reimbursement 6.9.1 Participating Provider Reimbursement A non-participating provider is defined as a Sanford Health Plan will pay the provider when Practitioner and/or Provider who has not signed a member receives covered services from a a contract with Sanford Health Plan, directly or participating provider (physician, hospital, facility, indirectly, and not approved by Sanford Health Plan dentist, etc.). Contracted providers agree to accept to provide Health Care Services to Members with negotiated fee schedules as reimbursement in an expectation of receiving payment, other than full for covered services provided to members. Coinsurance, Copays, or Deductibles, from Sanford Provider offices may collect copay, estimated Health Plan. When a member receives covered deductible and coinsurance at the time of service. services from a non-participating provider, Sanford Any non-covered service can also be collected. Health Plan will allow the Sanford Health Plan’s established maximum allowed amount. Maximum Participating providers are not allowed to bill allowed amount is the amount established by members the difference between the amount Sanford Health Plan using various methodologies charged by the provider and the pre-negotiated for Covered Services and supplies. Sanford Health Sanford Health Plan allowable reimbursement. Plan’s Maximum Allowed Amount is the lesser of: The difference between the charged amount and the allowed amount is considered a provider write a) the amount charged for a Covered Service or off. Services not covered by Sanford Health Plan supply; or guidelines will be the responsibility of the member. b) inside Sanford Health Plan’s Service Area, This excludes, but is not limited to, services denied negotiated schedules of payment developed for untimely filing or services medically necessary. by Sanford Health Plan, which are accepted by Participating Practitioner and/or Providers; or For ND Medicaid Expansion, as of January 1, c) outside of Sanford Health Plan’s Service Area, 2018, to be considered a network provider, the using current publicly available data adjusted following must be applicable: Provider contracted for geographical differences where applicable: with Sanford Health Plan; and Provider must i. Fees typically reimbursed to providers be enrolled with the ND DHS Medicaid program for same or similar professionals; or as being affiliated with Sanford Health Plan; ii. Costs for Facilities providing the same or and Provider is located within the state of ND or similar services, plus a margin factor. one of the counties that border North Dakota in Minnesota, South Dakota and Montana. Federal Sanford Health Plan accepts claims directly regulations [42 CFR §438.602(b)] requires Sanford from non-participating providers. If the non- Health Plan to confirm enrollment with ND DHS participating provider does not submit claims prior to payment for dates of service after January to Sanford Health Plan, members may submit 1, 2018. Enrollment with the ND DHS Medicaid a member claim form. Claims, whether directly program does not require a provider to render from providers or from members, must be services to ND Fee-for-Services recipients. submitted within 180 days (365 days for ND North Dakota Medicaid Expansion enrollment Medicaid Expansion) from the date of service or guidance for providers is available at www. date of inpatient discharge. The member may sanfordhealthplan.com/providers/2018-NDME- contact Sanford Health Plan’s Customer Service Network-Changes. Any services provided to ND Department to discuss how to submit the required Medicaid Expansion recipients not meeting these information. Payment will be sent directly to the conditions will deny. Provider. If the Provider refuses direct payment, the member will be reimbursed the maximum allowed amount for the service. However there is an exception for North Dakota Medicaid Expansion members; Per federal and state regulations,

64 members cannot be reimbursed directly by the 6.9.4 Claim Edits for Professional Claims Plan for costs paid directly to Providers. Only the maximum allowed amount is applied to Sanford Health Plan utilizes Experian the Member’s benefits. SHP may take additional editing software to apply correct coding and reductions based on the member’s benefits. The standardization for editing of professional claims. payment reduction does not apply toward the We consider and apply industry standard edits member’s out-of-pocket maximum amount. as outlined by National Correct Coding Initiative, American Medical Association and Centers The following policy(s) are referenced in this section and are available for review under for Medicare & Medicaid Services guidelines. “Resources” at sanfordhealthplan.com/ Authorizations or referrals do not override system providerlogin. claim edits. Edits made to claims are considered to be a provider adjustment and not billable to the • Non-Participating Provider Compensation member. Edits will be applied to both participating (PR-32) and non participating providers.

6.9.3 Modifiers 6.9.5 Inpatient Services

Modifiers are two digit codes which are used to Services are considered inpatient when a member indicate when a service or procedure has been has been admitted to the hospital (exception: altered or modified by some specific circumstance less than 24 hours). All charges incurred during without altering or modifying the basic definition the hospital stay are to be submitted timely for of the CPT code. The use of some modifiers may reimbursement. The Plan includes the day of affect reimbursement. The following chart lists admission, but not the day of discharge when modifiers that Sanford Health Plan recognizes for computing the number of facility days provided to pricing increases or decreases. a Member. Timely filing begins from the date of discharge. Modifier Allowance of Description Code Fee Schedule Interim claims, sometimes referred to as split- Increased Procedural Services/ 22 Unusual Procedural Services 115% bills, allow hospitals to submit a claim for a portion of the patient’s inpatient stay. They contain bill 52 Reduced Services 85% types 112, 113 and 114. 54 Surgical Care Only 85% 80 Assistant Surgeon 20% 112 Inpatient – First claim 81 Minimum Assistant Surgeon 20% Assistant Surgeon (when qualified 113 Inpatient – Continuing claim 82 resident or surgeon not available to 20% assist the primary surgeon) 114 Inpatient – Last claim Medically supervised by a AD physician, more than four 50% concurrent anesthesia procedures. Interim claims are accepted by Sanford Health Physician Assistant, Nurse Practi- AS tioner, or Clinical Nurse 20% Plan for bill types 112 (first claim in series) Medical direction of two, three or four where the billed amount exceeds the greater of QK concurrent anesthesia procedures 50% $100,000 or the contracted outlier threshold where involving qualified individuals applicable. Continuing claims in the series will CRNA service: with medical direction QX by a physician 50% be accepted for bill type 113 if the billed amount Medical direction of one CRNA by an exceeds $100,000 per continuing claim. Claims QY 50% anesthesiologist received with bill type 114 will be accepted as final bill with the remaining billed charges. Interim claims not meeting these criteria will be denied. Provider may resubmit interim claims under

65 this criteria or file all charges with bill type 111 • Low flow oxygen, 3 LPM or less (admission through discharge). • Restorative therapy including ROM, functional maintenance 6.9.6 DRG Grouper for Inpatient Services Level 2: All Level I services and supplies and Sanford Health Plan uses Optum’s DRG grouper nursing hours greater than 3.5 and up to 5.0 hours software for grouping and assigning a CMS of Nursing care per patient per day (PPD) including: MS-DRG code to each inpatient claim for payment purposes where the provider contract uses DRG • Stage III and IV pressure ulcers methodology. Claims that are ungroupable or • Old tracheotomy care and supplies (2 or more group to an invalid DRG will be denied. The grouper suctionings per shift-3 shifts per day) version used will be based on the most current • NG, GI, G tube patient (enteral feeding pumps version available or as specified in your contract included) effective on the date of admission. • Simple IV therapy (hydration plus one medication is “simple”) 6.9.7 Skilled Nursing Health Levels of Care • Wound isolation not requiring a private room • Respiratory therapy 3 or more small volume Skilled Nursing Facility (SNF) is a facility, either (Nursing Department) freestanding or part of a hospital that accepts • PT/OT/ST once a day (minimum 2 fifteen patients in need of rehabilitation and/or medical minute units) up to one hour of therapy care that is of a lesser intensity than that received per day, 5 days per week including therapy in a hospital. Sanford Health Plan reimburses evaluation providers based on the levels of care billed. Providers are required to bill the appropriate level Level 3: All Level I and II services and supplies and of care for which services were provided. The all general nursing services that require 5.0 – 6.5 following levels of care and services shall be made Nursing hours per patient per day including: available to members in accordance with Plan • Post-surgery care and monitoring every four policies. hours • Complex medical care* Level 1: Semi private room and board; general • Complex IV management (multiple nursing up to three hours of nursing per patient medications) NOTE: The costs of the IV day (PPD) Including: medication is excluded from the per diem rate • Wound Care in excess of $35.00 PPD • State I and II pressure ulcers • Rehabilitation (PT, OT, ST a combination of 1-3 • Incontinent care; bowel and bladder training hours per day BID) • Colostomy/Ilestomy care • New tracheotomy; including teaching • Foley catheter care (maintenance and *Complex care is beyond routine skilled care where irrigation); including teaching the client needs a higher level of monitoring and/or • Insulin dependent diabetic care; including nursing intervention. teaching • Dressing changes DRG categories that are candidates for subacute • Routine laboratory include: • X-rays • Pulmonary/Respiratory • Pharmacy; (oral medications) • Cardiac/Circulatory • Routine supplies • Orthopedic • Routine durable medical equipment (wheel • Gastrointestinal chairs, walkers, canes, etc.) • Pancreas, liver, gall bladder and spleen • Respiratory therapy – 2 small volume disease nebulizers (Nursing Department) • Cancers and malignancies

66 • Kidney, urinary tract electronically, required documentation includes a • Wound/skin dated screen print, with the documented name of • Endocrine and metabolic disease the clearinghouse being used, of the claim being • Neurological/spinal accepted without error by the Plan. • Infections • Amputations 6.10 Reporting Fraud, Waste, and Abuse • Trauma (FWA)

Level 4: Clients that are outside the perimeters Detecting and preventing fraud, waste, and abuse of Levels 1-3 are reviewed on a case by case (FWA) is the responsibility of everyone. Sanford basis for admission. Admission would be Health Plan encourages providers, members, dependent on the Provider’s competencies affiliates, facilities, vendors, consultants and to administer the appropriate care and upon contractors to report any suspected Fraud, Waste an agreement for reimbursement. (i.e. all or Abuse to the SHP Compliance Officer directly ventilator care with and without weaning; by calling, emailing or anonymously through the nursing hours are greater than 6.5 PPD) hotline. 6.9.8 Claim Reconsiderations Sanford Health Plan will protect its corporate You will be granted a one-time review for claim assets and the interests of its members, reconsiderations if you think your claim was employers, and providers against those who processed incorrectly. Follow up on an adverse knowingly and willingly commit fraud or other benefit determination that affects claims wrongful acts. We will identify, resolve, recover processing must be submitted 60 days from the funds, report, and when appropriate, take legal date the Explanation of Payment (EOP) was issued. actions, if suspected fraud, waste, and/or abuse After this time frame has expired, claims may no have occurred. longer be reviewed. These items can be submitted online through your mySanfordHealthPlan provider A provider’s submission of a claim for payment account under the “Claims and Explanation of also constitutes the provider’s representation the Payment.” claim is not submitted as a form of, or part of, fraud and abuse as listed below, and is submitted The following policy(s) are referenced in this in compliance with all federal and state laws and section and are available for review under regulations. The definitions of fraud, waste and “Resources” at sanfordhealthplan.com/ abuse and examples follow. providerlogin. • Claim Re-Considerations (PR-14) Provider is responsible for providing guidance to employees, independent contractors, and 6.9.9 Proof of Timely Filing subcontractors regarding how to report potential compliance issues. Provider is responsible for Sanford Health Plan participating providers are promptly addressing and correcting all issues contractually obligated to file claims within 180 brought to your attention. days. For North Dakota Medicaid Expansion member, providers can file claims within 365 Providers are responsible for, and these days. Sanford Health Plan processes a “clean provisions likewise apply to, the actions of their claim” within 30 days of receipt of the claim and staff members and agents. Sanford Health 60 days for a “non-clean” claim. In North Dakota, Plan routinely verifies charges billed are in Sanford Health Plan will pay clean claims within accordance with the guidelines stated in this 15 days of receipt of the claim. Therefore, all payment policy and are appropriately documented claims are to be paid or processed within 60 in the member’s medical record. All payments days. Required documentation includes screen are subject to prepayment audits, post-payment prints from the billing system showing the date audits and retraction of over-payments. Any the claim was sent to the Plan. If claims are filed 67 amount billed by a provider in violation of this individuals and entities currently excluded policy and paid by Sanford Health Plan constitutes from participation in Medicare, Medicaid an overpayment and is subject to recovery. A and all Federal health care programs. provider may not bill members for any amounts Individuals and entities who have been due resulting from a violation of this policy. reinstated are removed from the LEIE. http://exclusions.oig.hhs.gov Prevention Techniques How to report? Both fraud and abuse can expose a Provider, contractor, or subcontractor to criminal and civil Sanford Health Plan requires everyone to exercise liability. Waste is generally not considered to be due diligence in the prevention, detection and caused by criminally negligent actions, but rather correction of Fraud, Waste and Abuse (FWA). the misuse of resources. Sanford Health Plan promotes an ethical Provider is responsible for implementing methods culture of compliance with all State and Federal to prevent fraud, waste, and abuse. Listed below regulatory requirements, and mandates the are some common prevention techniques. This list reporting of any suspected or actual FWA to is not meant to be all-inclusive. the Sanford Health Plan Compliance Officer by any means including emailing the confidential • Education related to Fraud, Waste and Abuse Sanford Health Plan Compliance Team email: • Validate all member ID cards prior to [email protected] or calling the rendering service anonymous Compliance Hotline: (800) 325-9402 • Ensure accuracy when submitting bills or claims for services rendered Definitions and Examples: • Submit appropriate Referral and Treatment forms Fraud is defined as: knowingly and willingly • Avoid unnecessary drug prescription and/or executing, or attempting to execute, a scheme medical treatment or artifice to defraud any health care benefit • Report lost or stolen prescription pads and/or program or to obtain (by means of false or fraudulent prescriptions fraudulent pretenses, representations, or • Screen all employees and contractors at time promises) any of the money or property owned by, of hire/contract and monthly thereafter to or under the custody or control of, any health care prevent reimbursement of excluded and/or benefit program. debarred individuals and/or entities. Two of the review resources are: Health care fraud examples include but are not ° SAM– The Excluded Parties List System limited to the following: (“EPLS”) is maintained by the GSA, now a • Misrepresentation of the type or level of part of the System for Awards Management service provided (“SAM”). The EPLS is an electronic, web- • Misrepresentation of the individual rendering based system that identifies those parties service excluded from receiving Federal contracts, certain subcontracts, and certain types 6.11 Accident Policy of Federal financial and non-financial assistance and benefits. The EPLS keeps Accident information is essential for determining its user community aware of administrative which insurance company has primary and statutory exclusions across the entire responsibility for a claim. Common situations government, and individuals barred from where another insurance company may be liable entering the United States. www.sam.gov for paying claims are motor vehicle accidents, or ° LEIE – List of Excluded Individuals and injuries at work. Sanford Health Plan contracts Entities list is maintained by HHS OIG and with Optum to contact members about claims provides information to the health care which another party may be liable. industry, patients and the public regarding Claims are sent to Optum based on diagnosis 68 codes. Members are contacted by Optum to costs of the member’s health care by a process investigate if a third party is liable. Claims will called Coordination of Benefits. Sanford Health be denied if another party is responsible for the Plan follows all statutory and administrative laws payment of the claim or there is no response from concerning coordination of benefits, as applicable the member. to the state in which the plan is domiciled.

Optum’s process is as follows. Sanford Health Plan The member has two obligations concerning will electronically send claim information to Optum Coordination of Benefits: daily. Optum then identifies possible accident related claims and calls the member three times 1. The member must inform Sanford Health by phone. If they are unable to reach them, they Plan and/or their provider regarding all health send out an inquiry questionnaire (IQ) and cover insurance plans. letter. The cover letter explains the relationship 2. The member must cooperate with Sanford between Sanford Health Plan and Optum and Health Plan by providing any information that why the information is needed. The IQ inquires is requested. whether the claim in question is due to an accident and gives the member a choice of providing the 6.12.1 Applicability information to Optum on the questionnaire, or by calling Optum’s toll-free number and talking The order of benefits determination rules govern directly to an Optum representative. the order in which each plan will pay a claim for benefits. The plan that pays first is called the Once Optum has sent the IQ, they wait ten days primary plan. The primary plan must pay benefits for a response. If after ten days they have no in accordance with its policy terms without regard response from the member, they send out a close to the possibility that another plan may cover some out letter and wait another ten days for a response. expenses. The plan that pays after the primary The close out letter explains that Optum has plan is called the secondary plan. The secondary been unsuccessful in their attempts to reach the plan may reduce the benefits it pays so that member and will be required to notify Sanford payments from all plans do not exceed 100 percent Health Plan to deny the claim(s) in question. of the total allowable expense.

If Optum has not received a response within this 6.12.2 Order of Benefit Determination Rules second 10-day period, they send advice to Sanford Health Plan to deny the claims in question for The Plan determines its order of benefits using the lack of information. This process normally takes first of the following rules which applies: approximately 25 days assuming Optum does not receive a response. Optum will identify about 10% of Sanford Health Plan’s claims in 24 hours, 80% in 6.12.3 Non-Dependent/Dependent 8 calendar days, 90% in 14 calendar days and 99% in 25 days. Optum’s toll free number that members The plan that covers the person as a Group can call to relay the requested information is member, member or subscriber (that is other than (800) 529-0577. as a dependent), are determined before those of the plan which covers the person as a Dependent. 6.12 Coordination of Benefits The plan that covers the individual as a dependent is secondary. If the person is also a Medicare Coordination of Benefits (COB) is a provision that beneficiary, Medicare is: allow families with two wage earners covered by health benefit plans to receive up to 100% coverage • secondary to the plan covering the person as a for medical services. If a member is covered by dependent another health plan, insurance, or other coverage • primary to the plan covering the person as arrangement, then Sanford Health Plan and/or other than a dependent insurance companies will share or allocate the 69 6.12.4 Dependent Child Covered Under as follows: More Than One Plan Who Has Parents Living o The plan of the custodial parent; Together o The plan of the spouse of the custodial parent; For a dependent child whose parents are married o The plan of the noncustodial parent; and or living together (married or not), or has a joint then custody agreement that does not specify one o The plan of the spouse of the noncustodial party has the responsibility to provide health care parent. coverage, the order of benefits is: o Active/Inactive Group Member

• The primary plan is the plan of the parent The plan covering the person as an active whose birthday is earlier in the year. employee who is neither laid off nor retired, or • If both parents have the same birthday, the dependent of an active employee when none of the plan that covered either of the parents longer above rules apply is primary. The plan covering is primary. the person as an inactive employee, for example retired, or dependent of an inactive employee when 6.12.5 Dependent Child of Separated or none of the above rules apply is secondary. Divorced Parents Covered Under More Than One Plan 6.12.6 Continuation Coverage

For a dependent child whose parents are not If a person whose coverage is provided under married, separated (whether or not they ever a right of continuation pursuant to a federal have been married) or are divorced, the order of or state law also is covered under another benefits is: plan, the following shall be the order of benefit determination: • If a court decree states that one of the parents is responsible for the child’s health care • Primary, the benefits of a plan covering expense and the plan is aware of the decree, the person as a Group Member, Member or the plan of that parent is primary. This rule Subscriber (or as that person’s Dependent); applies to claim determination periods or plan • Secondary, the benefits under the continuation years commencing after the Plan is given coverage. If none of the above rules notice of the court decree. determines the order of benefits, the benefits • If a court decree states that both parents of the plan which covered a Group Member, are responsible for the child’s health care Member or Subscriber longer is primary. expenses or assigns joint custody without specifying responsibility, the rule for If the preceding rules do not determine the primary “Dependent Child Who Has Parents Living plan, the allowable expenses shall be shared Together” will apply equally between the plans meeting the definition • If a court decree states that the parents of plan under this regulation. In addition, this plan have joint custody without specifying that will not pay more than it would have paid had it one parent has responsibility for the health been primary. care expenses or health care coverage of the dependent child, the first rule which applies to 6.13 Calculation of Benefits, Secondary Plan • non-dependent/dependent listed above shall determine the order of benefits or: When Sanford Health Plan is secondary, we shall • If the parents are not married, or are reduce benefits so that the total benefits paid or separated (whether or not they have been provided by all plans for any claim or claims do not married) or are divorced and there is no court exceed more than 100 percent of total allowable decree allocating responsibility for the child’s expenses. In determining the amount of a claim to health care expenses or coverage, the order is be paid by Sanford Health Plan, we calculate the

70 benefits that we would have paid in the absence of payments will be subject to the applicable State’s other insurance and apply that calculated amount right to reimbursement for benefits it has paid on to any allowable expense that is unpaid by the behalf of the Covered Individual, as required by primary plan. We may reduce our payment by any such state’s Medicaid program; and Sanford Health amount that, when combined with the amount paid Plan will honor any subrogation rights the State by the primary plan, exceeds the total allowable may have with respect to benefits that are payable. expense for that claim. When an individual covered by Medicaid also has coverage with Sanford Health Plan, Medicaid is Where there is a difference between the amounts the payer of last resort. If also covered under the plans allow, we will base our payment on the Medicare, Sanford Health Plan pays primary, then higher amount. However, if the primary plan has a Medicare, and Medicaid is tertiary. See provisions contract with the provider, our combined payments below on Coordination of Benefits with TRICARE, will not be more than the amount called for in our if a member is covered by both Medicaid and contract or the amount called for in the contract of TRICARE. the primary plan, whichever is higher. This is also known as the “greater of” rule. 6.16 Coordination of Benefits with TRICARE

6.14 Coordination of Benefits with Medicare Generally, TRICARE is the secondary payer if the TRICARE beneficiary is enrolled in, or covered by, Medicare benefits provisions apply when a member any other health plan to the extent that the service has health coverage under Sanford Health Plan provided is also covered under the other plan. and is eligible for insurance under Medicare Parts Sanford Health Plan pays first if an individual is A and B, (whether or not the member has applied covered by both TRICARE and Sanford Health Plan, or is enrolled in Medicare). This provision applies as either the Member or Member’s Dependent; before any other coordination of benefits provision and a particular treatment or procedure is covered of Sanford Health Plan. under both benefit plans. TRICARE will pay last; TRICARE benefits may not be extended until all If a provider has accepted assignment of Medicare, other double coverage plans have adjudicated the Sanford Health Plan determines allowable claim. When a TRICARE beneficiary is covered expenses based upon the amount allowed by under Sanford Health Plan, and also entitled to Medicare. Our allowable expense is the Medicare either Medicare or Medicaid, Sanford Health Plan allowable amount. We will pay the difference will be the primary payer, Medicare/Medicaid will between what Medicare pays and our allowable be secondary, and TRICARE will be tertiary (last). expense. TRICARE-eligible employees and beneficiaries receive primary coverage under this Certificate The Plan shall coordinate information relating of Coverage in the same manner, and to the same to prescription drug coverage, the payment of extent, as similarly situated employees of the Plan premiums for the coverage, and the payment for Sponsor (Employer) who are not TRICARE eligible. supplemental prescription drug benefits for Part D eligible individuals enrolled in a Medicare Part For North Dakota Medicaid Expansion members, D plan or any other prescription drug coverage. TRICARE is the primary payer if the TRICARE Sanford Health Plan will make this determination beneficiary is enrolled in, or covered by, Medicaid based on the information available through CMS. Expansion to the extent that the service provided is also covered. When a TRICARE beneficiary 6.15 Coordination of Benefits with Medicaid is covered under this plan, and also entitled to Medicaid Expansion, TRICARE will be the primary A Covered Individual’s eligibility for any State payer, absent other coverage, and Medicaid Medicaid benefits will not be taken into account in Expansion will be tertiary (last). TRICARE-eligible determining or making any payments for benefits Members receive primary coverage under this to or on behalf of the member. Any such benefit Plan’s provisions in the same manner, and to the

71 same extent, as similarly situated Members who 6.18.2 Bilateral Procedures are not TRICARE eligible. If a procedure is performed on both sides of the 6.17 Members with End Stage body it is considered to be bilateral. Bilateral Renal Disease (ESRD) procedures are identified with a modifier 50. Bilateral procedures follow the same The Plan has primary responsibility for the claims reimbursement percent guidelines as listed above of a Member: under multiple surgical procedures. Bilateral a. Who is eligible for Medicare secondary procedures should be billed on one line. See the benefits solely because of ESRD, and; below example. b. During the Medicare coordination period of 30 months, which begins with the earlier of: Example: Bilateral procedures billed on one line i. the month in which a regular course of (two services). renal dialysis is initiated, or ii. in the case of an individual who receives CPT Modifier Description Charges Units a kidney transplant, the first month in Removal of impacted cerumen requiring 69210 50 $400.00 1 which the individual became entitled to instrumentation, Medicare. unilateral The Plan has secondary responsibility for the claims of a Member: To ensure accurate payment, please make sure to a. Who is eligible for Medicare primary bill the full billed amount versus billing with the benefits solely because of ESRD, and; pre-cut amount. We are not able to recognize a b. The Medicare coordination period of 30 claim pre-cut, and our system will cut according to months has expired the bilateral procedures guidelines.

6.18 Billing Requirements 6.18.3 Assistant Surgeons

6.18.1 Multiple Surgeries Assistant surgeon claims can be identified by modifier 80, 81 or 82. Claims with modifiers 80, 81 Multiple surgeries are defined as multiple or 82 will be adjudicated according to the Milliman procedures performed at the same session by the Care Guidelines (MCG) for Assistant Surgeon same provider. Sanford Health Plan allowances Care. Assistant surgeon fees should not be billed are reduced for multiple surgical procedures. pre-cut. Surgeries that allow an assistant will be Multiple surgical procedures should be identified reimbursed 20% of the applicable allowable. with a modifier 51. The exceptions to the above are subsidiary codes listed by Medicare and services Claims will be denied for those surgeries that performed within the scope of ear, nose & throat do not require an assistant surgeon. Assistant and otolaryngology specialists (these do not get surgeon charges that are denied may not be cut to 25%). These subsidiary codes should not billed to the member. Participating providers be coded with a 51 modifier and the allowance. are contractually obligated to write off assistant Multiple surgery fees should not be billed pre-cut. surgeon fees that are not covered by Sanford Sanford Health Plan uses the following payment Health Plan. A list of codes that are not allowed for structure for multiple surgery claims. assistant surgeons according to MCG, can be found by clicking this link: Requests for reconsideration • 100% of the fee schedule for the highest of denied assistant surgeon charges must be allowable procedures received within 60 days of the denial date on • 50% of the fee schedule for the second highest the EOP and can be submitted using the claim allowable reconsideration form found online. Please include • 25% of the fee schedule for any additional a reference to the claim number, code(s) being surgical procedures asked for reconsideration and a copy of the medical record. 72 6.18.4 OB/GYN Global Package Serious Reportable Event when permitted by Billing/Antepartum Care contract. Providers are not permitted to bill members for these services and must notify Claims must be submitted within 180 days from the the Plan, within five days of the occurrence. The date of delivery. After this time frame has expired, conditions which are not reimbursable include claims will no longer be reviewed. Required the 28 events listed on the National Quality Forum documentation includes date of delivery. (NQF) website.

6.18.5 Newborn Additions The following policy(s) are referenced in this section and are available for review under A newborn is eligible to be covered from birth. “Resources” at sanfordhealthplan.com/ Member’s must complete and sign an enrollment providerlogin. application form requesting coverage for the newborn within 31 days of the infant’s birth. • Never Events and Avoidable Hospital Because of this timeframe to add newborn Conditions Policy (MM-14) dependents to a policy, providers should not file claims prior to the 31 days of an infant’s birth. 6.18.7 Site of Service Differential Claims received prior to the newborn being added to a policy may be denied or rejected electronically Site of Service Differential: Some professional as “member not eligible.” Providers will need to services may be provided either in a facility or a re-file claims timely after the newborn is enrolled non-facility setting. When a professional service for proper claims processing and reimbursement. is provided in a facility, the costs of the clinical personnel, equipment, and supplies are incurred 6.18.6 Never Events, Avoidable Hospital by the facility, not the physician practice. For this Conditions and Serious Reportable Events reason, reimbursement for professional services provided in a facility may be lower than if the Never events, avoidable hospital conditions, services were performed in a non-facility setting. and serious reportable events are defined in This difference in reimbursement, based on where the following table. The definitions have been the professional service is performed, is referred developed by the National Quality Forum and CMS to as a “site of service differential.” in collaboration with multiple partners, including the AMA. In accordance with 2017 CMS guidelines, professional providers will be reimbursed based on Conditions which could have been prevented the site of service where the selected procedures through application of evidence-based Avoidable Hospital guidelines. These conditions are not present are performed. Only codes that have a site of Conditions on admission, but present during the course service differential are included in Sanford Health of the stay. Plan’s list of applicable procedures for differential Errors in medical care that are clearly identifiable, preventable, and serious in their reimbursement. This only applies to provider Never Event consequences for patients and that identify contracts that include Site of Service differential. a problem in the safety and credibility of a health care facility. An event that results in a physical or The CPT® codes and nomenclature used in this mental impairment that substantially limits one or more major life activities of an Policy are subject to revision and/or change by the Serious individual or a loss of bodily function, if the American Medical Association. In the event of such impairment or loss lasts more than seven Reportable Event days or is still present at the time of discharge changes, the Policy will continue to be in force, from an inpatient health care facility. albeit applied to the new or amended coding so Serious events also include loss of a body part and death. issued until such time as the Policy is reviewed and updated to reflect the new or amended coding. Sanford Health Plan does not provide reimbursement for services associated with a Sanford Health Plan uses CMS’s list of procedure Never Event, Avoidable Hospital Condition, or codes where there is a difference between the

73 facility and non-facility RVUs that are in effect QX, or QY, will be reimbursed at 50% of the allowed at the time Sanford Health Plan’s current fee amount, due to the supervision/services shared schedule year was implemented. Sanford between two providers. Time-based anesthesia Health Plan will review the list of site of service services must be reported with actual anesthesia procedures codes and places of service upon time in one-minute increments. Anesthesia time contract renewal. calculates a unit for every 15 minute interval, rounding up to the next unit for 8-14 minutes, The table below includes current national place rounding down for 1 to 7 minutes. Sanford Health of service code set information that identifies the Plan will not reimburse for services billed by facility and non-facility designations for each code. anesthesia students.

POS Description Billing instructions: 02 Telehealth 19 Outpatient Hospital – Off campus • Services involving administration of anesthesia require the use of a valid five digit 21 Inpatient Hospital procedure code plus the appropriate modifier 22 Outpatient Hospital – On campus code. Emergency Room – Hospital 23 • Providers are to bill the full charge amount for 24 Ambulatory Surgery Center services. 26 Military Treatment Facility • Report elapsed time in minutes in item 24g on 31 Skilled Nursing Facility (SNF) – Part A the CMS-1500 claim form. 34 Hospice • Convert hours to minutes and enter total 41 Ambulance - Land minutes. 42 Ambulance – Air or Water 51 Inpatient Psych Facility Time-Based Anesthesia claims are typically paid based on the following: 52 Psych Facility – Partial Hospitalization Community Mental Health Center 53 ([Base Unit + Time Units] x Anesthesia Conversion 56 Psych Residential Treatment Center Factor) x Modifier Percentage 61 Comprehensive Inpatient Rehabilitation Facility

6.18.8 Anesthesia Modifier Allowance of Description Code Fee Schedule Anesthesia is the administration of a drug or Anesthesia services performed AA personally by an anesthesiologist 100% anesthetic agent by an anesthesiologist or Medically supervised by a physician, certified registered nurse anesthetist (CRNA) for AD more than four concurrent anesthe- 50% medical or surgical purposes to relieve pain and/ sia procedures. or induce partial or total loss of sensation and/or Medical direction of two, three or four QK concurrent anesthesia procedures 50% consciousness during a procedure. Sanford Health involving qualified individuals Plan covers the administration of anesthesia for CRNA service: with medical direction QX 50% medically necessary services rendered to Sanford by a physician Medical direction of one CRNA by an Health Plan members. QY anesthesiologist 50% CRNA service: without medical QZ 100% Medically directed anesthesia: Sanford Health Plan direction by a physician utilizes the base value unit, as reported by CMS, and the actual time units necessary to perform the Labor Epidurals - Time related to neuraxial anesthesia service to determine its reimbursement labor anesthesia is different than operative amount. The physician and the CRNA shall append anesthesia according to the American Society the appropriate modifiers to all anesthesia of Anesthesiologists (ASA). The number of services provided. Services submitted with minutes and charges billed should only reflect medical direction or supervision, modifiers AD, QK, the time the anesthesiologist or CRNA is present 74 for preparation, insertion and monitoring of Additional claims criteria: the epidural which should coincide with the intensity and direct time involved for performing • Patient presents with early labor and is sent and monitoring neuroaxial labor analgesia. home and then subsequently delivers at a later Complications that are present and that require date; appropriate to submit separate charges the constant attendance of the anesthesiologist or payment for pre-labor monitoring services. or CRNA should be billed appropriately with • Patient presents on multiple, distinct, time unites that reflect the full time the epidural encounters with early labor; each encounter catheter is in place but should not be the standard. should be submitted separately Consistent with a method described in the ASA • Patient delivers while being monitored for guidelines, Sanford Health Plan will cap the Time early labor; no separate outpatient charges Units used to reimburse labor epidurals (CPT code or payment should be submitted and should 01967) at 5 Units (75 minutes) unless constant subsequently be included in the inpatient attendance by an anesthesiologist or CRNA is delivery stay. medically necessary. • Other ancillary services will continue to be billed separately on the same claim. ([Base Unit + Time Units (Not to Exceed 5)] • Additional services submitted will be subject x Anesthesia Conversion Factor) x Modifier to APC logic when the provider is under an Percentage APC contract.

6.18.9 Outpatient Pre-Labor Monitoring 6.18.10 Inpatient Services Services Services are considered inpatient when a member Sanford Health Plan separately reimburses has been admitted to the hospital (exception: less outpatient pre-labor monitoring services based than 24 hours). All charges incurred during the on individual provider contract percent of charges. hospital stay are to be submitted timely for reim- The following billing and claim submission bursement. The Plan includes the day of admis- requirements will apply: sion, but not the day of discharge when computing the number of facility days provided to a Member. Billing instructions: Timely filing begins from the date of discharge. Interim claims, sometimes referred to as split- • Providers must bill pre-laboring monitoring bills, allow hospitals to submit a claim for a portion services with revenue code 072x – Labor of the patient’s inpatient stay. They contain bill Room/Delivery (excluding revenue code 0723 types 112, 113 and 114. – circumcision). • Providers must bill the following HCPCS code for these services: 112 Inpatient First claim o S4005: Interim labor facility global (labor 113 Inpatient Continuing claim occurring but not resulting in delivery) 114 Inpatient Last claim • Units must reflect the number of hours the

patient was being monitored. Interim claims are accepted by Sanford Health Plan • Pre-labor monitoring using revenue code 072x for bill types 112 (first claim in series) where the and HCPCS S4005 should not be submitted on billed amount exceeds the greater of $100,000 or the same claim as observation using G0378 as the contracted outlier threshold where applicable. this reflects duplication of services. Continuing claims in the series will be accepted for • Additional nursing charges in the labor/ bill type 113 if the billed amount exceeds $100,000 delivery room are not separately billable. per continuing claim. Claims received with bill type • Fetal monitoring and fetal stress or non- 114 will be accepted as final bill with the remaining stress tests should be billed using revenue billed charges. Interim claims not meeting these code 0732 with the appropriate CPT®/HCPCS criteria will be denied. Provider may resubmit code. interim claims under this criteria or file all charges 75 with bill type 111 (admission through discharge). • Routine laboratory • X-rays 6.18.11 DRG Grouper for Inpatient Services • Pharmacy; (oral medications) • Routine supplies Sanford Health Plan uses Optum’s DRG grouper • Routine durable medical equipment (wheel software for grouping and assigning a CMS MS- chairs, walkers, canes, etc.) DRG code to each inpatient claim for payment • Respiratory therapy – 2 small volume purposes where the provider contract uses DRG nebulizers (Nursing Department) methodology. Claims that are ungroupable or group • Low flow oxygen, 3 LPM or less to an invalid DRG will be denied. The grouper ver- • Restorative therapy including ROM, functional sion used will be based on the most current version maintenance available or as specified in your contract effective on the date of admission. Level 2: All Level I services and supplies and nursing hours greater than 3.5 and up to 5.0 6.18.12 Skilled Nursing Health Care Services hours of Nursing care per patient per day (PPD) including: Skilled Nursing Facility (SNF) is a facility, either • Stage III and IV pressure ulcers freestanding or part of a hospital that accepts • Old tracheotomy care and supplies (2 or more patients in need of rehabilitation and/or medical suctionings per shift-3 shifts per day) care that is of a lesser intensity than that received • NG, GI, G tube patient (enteral feeding pumps in a hospital. Sanford Health Plan reimburses included) providers based on the levels of care billed. • Simple IV therapy (hydration plus one Skilled nursing services must be billed with the medication is “simple”) appropriate Rev code in box 42 of the UB-04 • Wound isolation not requiring a private room claim form for which services received prior • Respiratory therapy 3 or more small volume authorization. Rev codes shall correspond to a (Nursing Department) level of care as defined in the following table: • PT/OT/ST once a day (minimum 2 fifteen minute units) up to one hour of therapy per day, 5 days Skilled Nursing Level of Care Rev Code per week including therapy evaluation Level 1 191 Level 2 192 Level 3: All Level I and II services and supplies Level 3 193 and all general nursing services that require 5.0 – 6.5 Nursing hours per patient per day including: Level 4 194 • Post-surgery care and monitoring every four hours The following levels of care and services are • Complex medical care* further defined and shall be made available to • Complex IV management (multiple members in accordance with Plan policies. medications) NOTE: The costs of the IV medication is excluded from the per diem rate Level 1: Semi private room and board; general in excess of $35.00 PPD nursing up to three hours of nursing per patient • Rehabilitation (PT, OT, ST a combination of 1-3 day (PPD) Including: hours per day BID) • Wound Care • New tracheotomy; including teaching • State I and II pressure ulcers

• Incontinent care; bowel and bladder training *Complex care is beyond routine skilled care where the client needs a • Colostomy/Ilestomy care higher level of monitoring and/or nursing intervention. • Foley catheter care (maintenance and irrigation); including teaching DRG categories that are candidates for subacute • Insulin dependent diabetic care; including include: teaching • Pulmonary/Respiratory • Dressing changes • Cardiac/Circulatory

76 • Orthopedic Respite care is a very short inpatient stay • Gastrointestinal given to a hospice patient so that the usual • Pancreas, liver, gall bladder and spleen disease caregiver can rest. Hospice and respite services • Cancers and malignancies are to be billed with the appropriate revenue • Kidney, urinary tract code in box 42 of the UB-04 claim form. • Wound/skin • Endocrine and metabolic disease Hospice Service Revenue Code • Neurological/spinal Home Care (routine) 651 • Infections Continuous Home Care 652 • Amputations Respite Care 655 • Trauma Cottiage/General Inpatient 656 Level 4: Clients that are outside the perimeters of 6.19 Ambulatory Payment Classification Levels 1-3 are reviewed on a case by case basis (APC) Payment for Outpatient Services for admission. Admission would be dependent on the Provider’s competencies to administer Sanford Health Plan implemented APC pricing the appropriate care and upon an agreement for methodology for outpatient service in 2016. We reimbursement. (i.e. all ventilator care with and follow the general principles, billing, pricing, without weaning; nursing hours are greater than and edit guidelines of the Center for Medicare & 6.5 PPD) Medicaid Services (CMS) outpatient prospective payment/ambulatory payment classifications (OPPS/APC’s) unless otherwise stated in individual 6.18.13 Home Health Care Services contracts. APC methodology is used for covered outpatient services at Prospective Payment System Home health care is a wide range of health care hospitals and General Acute Care facilities. services that can be given in your home for an illness or injury. Home health care is usually less Sanford Health Plan uses Optum’s EASYGroup™, expensive, more convenient, and considered just ECM Pro, Client Hosted Web.Strat Rate Manager as effective as care received in a hospital or skilled APC software to deliver Ambulatory Payment nursing facility (SNF). Home health care services Classification (APC) pricing methodology for are billed using a combination of revenue codes, outpatient services billed via the UB-04 claim (or HCPCS codes and units. Units are calculated for electronic equivalent) with bill types 13X or 14X. every 15 minute interval for which services were This product seamlessly integrates with Sanford rendered. Health Plans’ EPIC Tapestry host systems. We

began using Ambulatory Payment Classification Home Health Service Revenue Code HCPCs Code (APC) pricing methodology to help control cost G0299 or Skilled nurse visit 551 and utilization of services. This is the result of a G0300 national trend in decreased inpatient volume and Physical therapy visit 421 G0151 an increase in outpatient services. It is intended Occupational therapy 431 G0152 visit to provide an opportunity to level set for both the provider and payer, while reimbursing the provider Speech therapy visit 441 G0153 for the resources utilized for the services. Home health aid visit 571 G0156 APC pricing/methodology is not considered for: 6.18.14 Hospice & Respite Care Services • Durable Medical Equipment (DME) services. Hospice services are for those who are terminally Providers will need to submit separate claims ill (with six months or less to live). The goal of for these services; hospice is to provide comfort for terminally ill • Ambulance services. Providers will need to patients and their families, not to cure illness. submit separate claims for these services;

77 • Critical Access Hospitals; • Indian Health Service Hospitals; • Invalid Billing of Device Credit Logic: These • Maryland hospitals under PPS waiver; condition codes, value amounts, and value • Hospitals in Guam, Saipan, America Samoa, codes will be accepted but not required. and the Virgin Islands; Payment will be adjusted, similar to Medicare’s • Partial Hospitalization. Payment for outpatient pricing policy, when the condition codes, value mental health services are will be based on amounts, and value codes are submitted on a one of six H or S codes; claim. • Physician/professional services. Providers o Condition Codes 49 or 50 will need to submit separate claims for these o Value Amount on claims that include Value services. Code FD

6.19.1 APC Payment Groups • Observation: The Plan will process and reimburse observation claims spanning Each HCPCS code for which separate payment is greater than 72 hours as follows: made under the OPPS is assigned to an APC group. o The first 72 hours of observation will be The payment rate for an APC applies to all of the billed on one UB-04 claim line with the admit services assigned to the APC. APC payment rates date of service; are calculated using the following methodology: o Any additional hours over 72 will be billed on (Provider specific conversion factor x APC-specific a separate UB-04 claim line with a different weight). A hospital may receive a number of APC date of service than the admit date. payments for the services furnished to a patient on o These two lines of observation, reflecting a single day on the same claim; however, certain the entire stay, must be billed on the same services are subject to discounting for multiple UB-04 claim form. procedures. Services within an APC are similar o For observation billing, the admit date clinically and with respect to hospital resource use. of service is defined to be the date when observation services are initiated. 6.19.2 APC Billing Rules • Pre-labor Monitoring: Pre-labor monitoring Sanford Health Plan will follow CMS APC billing services should be submitted according to SHP guidelines including: guidelines.Providers should submit revenue code 072x, excluding 0723 (circumcision) for • Instances where CMS requires an alternative pre-labor monitoring services using HCPCS code (ex. Observation, clinic, MRIs); S4005. The units should reflect the number of • CPT/HCPCS code on lines with Self- hours the patient was being monitored. Administrable Drugs (Rev Code 637);Outpatient • Take Home Drugs/Supplies & observation services and pay observation on a Self-Administrable Drugs: The following comprehensive APC basis; revenue codes require valid HCPCS codes and • Packaging rules within CMS Outpatient Code should be submitted with the most specific Editor (OCE); code available. • Late charges – a corrected claim must be o 0253: Take Home Drugs submitted if all services are not included on o 0273: Take Home Supplies the original claim. o 0637: Self-Administrable Drugs

Sanford Health Plan deviates from CMS (Providers should not use HCPCS code A9270, on the following guidelines: non-covered item or service, as this is a member liable denial per benefit design.) Any take-home drugs or supplies without a specific • Chemotherapy Medications: Imatinib, 100 mg, for both Imatinib and Gleevac will require code should be submitted on the generic HCPCS S0088 to be billed for appropriate revenue codes below: payment. 78 o 0250: Pharmacy, General Insufficient services on day or partial 30 o 0259: Pharmacy, Other hospitalization o 0270: Medical/Surgical Supplies, General Only mental health education & training 35 services provided For services submitted with a HCPCS code, 45 Inpatient separate procedures not paid reimbursement will be driven off of the OPPS Partial hospitalization condition code 41 not 46 appropriate for bill type status indicator associated with the procedure code submitted and will be reimbursed either at the fee 49 Service on same day as inpatient procedure schedule rate or the default percent of charges 61 Service can only be billed to the DMERC per the provider’s contract. Services submitted 65 Revenue code not recognized by Medicare under one of the generic revenue codes above will Mental health code not approved for Partial 80 Hospitalization Program be either packaged into the reimbursement for Mental health services not payable outside 81 the other primary services on the claim that were Partial Hospitalization Program paid under APC’s or they will be reimbursed at the default percent of charges per the provider’s 6.19.3 APC Pricing Rules contract. Sanford Health Plan will follow CMS APC pricing • Therapy services: These modifiers and rules including the following: G-codes will be accepted but not required. • CMS APC Weight File o Modifiers GN, GO, GP • CMS Lab packaging(PSI Q4) o Non-payable therapy G-codes • CMS Lab paneling / multi-channeling logic o Functional severity Modifiers (CH – CN) • Limit fee schedule payment to line item charge Payment rules for Partial Hospitalization: Payment (i.e. Lab, DME, Therapies) for outpatient mental health services will be based • Cost outliers pricing logic applied on Rev Codes or one of six H or S HCPCS codes o Source for ratio of cost to charge (RCC) below per individual contract language. will be CMS value effective based on date quoted in provider contract. RCC will be Code Description held constant until the updating processing

Intensive outpatient psychiatric associated with the next provider contract S9480 IOP services, per diem year Alcohol or other related drug o Cost outlier payment percent to be H2035 treatment program, per hour IOP comparable to CMS (ex. 50%) effective at H0015 Alcohol and/or drug services IOP the start of the contract year Mental PHP, treatment, less H0035 than 24 hours PHP o Source for payment factor (ex. 1.75) will PHP services, less than 24 hours, be CMS value effective at the start of the S0201 PHP per diem contract year Behavioral health day treatment, H2012 PHP o Source for fixed threshold (ex. $3,250) will per hour be CMS value effective at the start of the Codes mapped out of relevant OCE and paid at contract year either fee schedule rate or default to percent of charge due to Sanford Health Plan will also apply the differences in demographic and benefit design. following guidelines: • Claim level lesser of logic Outpatient Code Description • Provider specific conversion factors Editor (OCE) Number • No wage adjustments 12 Questionable covered service • Categories of covered codes with no specific 18 Inpatient procedure pricing will default to specific % of charge Medical visit same day as significant 21 procedure without modifier 25 stated in the contract (i.e. Inpatient Only Partial hospitalization service non-mental Procedures PSI C, dialysis on TOB 13x/14x) 29 health diagnosis • Vaccines (PSI F and L): Pay based on code

79 specific fee schedule amounts where APC Updates: available. If no fee schedule available, pricing will default to contract specific rate percent of Sanford Health Plan will review updates released billed charges by CMS. • CMS fee schedules for North Dakota, South Dakota, and Minnesota will be used based on These updates may result from: where services were rendered • Changes in technology 6.19.4 OCE Edits • Changes in CPT codes • Codes removed from Inpatient Only List The role of OCE is to edit claims for errors, notify • New procedures or services Sanford Health Plan what action to take with a • Changes in resources used to perform “problem” claim, assign payment categories/ services groups and pre-process data for APC pricing. Editing categories used in OCE include: Updates include: Quarterly updates to: • Validity edits • New CMS codes • Invalid age • OCE files including CMS CCI/MUE • Invalid sex (Medically Unlikely Edits • Diagnosis/procedure and age or sex conflicts • CMS Payment weights • Appropriate use of modifiers • Packaging rules within CMS Outpatient • Volume/unit edits Code Editor (OCE) • Revenue code that require HCPCS codes • Conditions not payable under OPPS Annual updates to: per CMS regulations • National Correct Coding Initiative (CCI) • Payment adjustments • Edits that implement payment policies • Reweighting of conversion factor implemented • Plan/DME exclusions based on the January CMS date • Composite APCs • RCC factor based on latest RCC available for Due to OCE claim edits, your claim may be Optum through HCRIS returned or denied. • APC Grouper Version • The Plan will apply updates for applicable APC OCE Edit OCE Edit Description groupings, new codes, and weights according 001 Invalid Diagnosis Code to the final rule published by CMS quarterly. 005 E-Code as Reason for Visit Invalid HCPS Procedure Code: invalid code, 1. The Plan will delay implementation of the 006 or code invalid for service dates quarterly update one calendar month to 027 Only incidental services reported provide adequate time for review of CMS 048 Revenue center requires HCPCS code updates, configuration, and testing. H2012 Behavioral health day treatment, per hour o May 1 o August 1 o November 1 o February 1

2. Claims received by the Plan during one month interim will be reimbursed according to the groupings, weights, and codes in the payment system at the time received which will reflect the previous quarter’s updates based on date of service.

80 Example: Claims submitted with January Sanford Health Plan Provider Contracting will send dates of service in January will be reimbursed annual reimbursement notice that will include according to the groupings, weights, and codes conversion factor and RCC. from the 4th quarter of the previous year We will provide notice of action plan in the event CMS 3. Claims received by the Plan after the one month has a delay in releasing updates. delay will be reimbursed according to the We encourage providers to visit the following CMS updated file in the payment system at the time website links for further details regarding APC claim received based on date of service. processing.

Example A: Claims submitted with February Addendum A & B Updates where APC states codes dates of service in February will be are updated: reimbursed according to the groupings, weights, and codes from the 1st quarter of General CMS Hospital Outpatient OPPS Information: that year. Example B: Claims submitted with January National Correct Coding Initiative Edits/MUE’s: dates of service in February will be reimbursed according to the groupings, Select facility outpatient services MUE table at the weights, and codes from the 4th quarter of bottom of the page. the previous year.

4. Claims incurred by the Plan during the one month interim will not be reprocessed by The Plan.

5. The Plan will reimburse any new codes according to the contracted Outpatient All Other Services % of charge for claims received by The Plan during one month delayed implementation.

6. For the January CMS update, the Plan will implement an adjustment factor budget neutral to the Plan based on the aggregate weight change between the new APC weights and the current weights derived from historical claims.

81 Members 7.1 Problem Resolution A written notification including the decision regarding the complaint will be sent to the The following individuals have the right to file a complainant who filed the complaint within 30 complaint or appeal of any adverse determination calendar days from the receipt of the complaint. made by Sanford Health Plan: In certain circumstances, the time period may be extended to 14 days beyond the initial 30 days. • a member • a health care provider with knowledge of the For North Dakota Medicaid Expansion members, • member’s medical condition, or a complaint (grievance) may be filed orally or in • a member’s authorized representative or an writing. No written documentation is required for attorney. further review of the complaint to take place. The plan will acknowledge receipt of the complaint, as For members of the North Dakota Medicaid well as provide the Member and any party filing Expansion Program, a provider must obtain written on the Member’s behalf, with a response within 90 consent from the member prior filing a complaint calendar days of the date the complaint is received. or appeal on their behalf. If additional time is needed to investigate the complaint, and the added time is in the Member’s 7.1.1 Oral Complaint benefit, the Plan may extend the allotted 90 calendar day time frame once, by 14 calendar days. A complaint can be submitted by calling the Customer Service Department. If the complaint is 7.1.2 Written Complaint not resolved within 10 business days of receipt of A complainant can seek further review of a the complaint, then a Complaint Form will be sent Complaint not resolved by phone by optionally to the person calling. The form must be completed choosing to submit a written Complaint form. A and returned to the Customer Service Department Member, or his/her Authorized Representative for further consideration. may send the completed Complaint form, including comments, documents, records and other The completed form can be accompanied by information relating to the Complaint, the reasons comments, documents, records and other they believe they are entitled to benefits and any information relating to the reason for filing a other supporting documents to: written complaint. Customer Service will notify the individual that filed the complaint within 10 Sanford Health Plan business days upon receipt of the information, Customer Service Department unless the complaint has been resolved to the PO Box 91110 complainant’s satisfaction within those 10 business Sioux Falls, SD 57109-1110 days. or Fax: (605) 328-6812 82 A written complaint may also be submitted through contact Customer Service at (800) 752-5863. The the secure communications portal of a Member’s following policy(s) are referenced in this section online account at www.sanfordhealthplan.com. and are available for review inside the provider portal under “Resources” at sanfordhealthplan. 7.2 Appeals com/providerlogin. • Medical Management Program Policy (MM-49) 7.2.1 Expedited Appeal 7.3 Member Rights An Expedited Appeal for Urgent Care is a request to change a previous adverse determination made 7.3.1 South Dakota, Iowa, Minnesota and by Sanford Health Plan for an urgent care request. North Dakota Member Rights: If the member’s situation meets the definition of urgent, a determination will be made within 72 The Plan is committed to treating members hours. in a manner that respects their rights. In this regard, the Plan recognizes that each member 7.2.2 Prospective Appeal (or the member’s parent, legal guardian or other representative if the member is a minor or A Prospective (pre-service) Appeal is a request incompetent) has the right to the following: to change an adverse determination that Sanford Health Plan approved in whole or in 1. Members have the right to receive impartial part in advance of the member obtaining care or access to treatment and/or accommodations services. A determination will be sent in writing or that are available or medically indicated, electronically within 30 calendar days of receipt of regardless of race; ethnicity; gender; gender the appeal (15 calendar days for some Self-Funded identity; sexual orientation; medical condition, and elite1 members) to the member or their including current or past history of a mental representative and/or any practitioner involved in health and substance use disorder; disability; the appeal. religious beliefs; national origin; age; or sources of payment for care, in accordance 7.2.3 Retrospective Appeal with access and quality standards. 2. Members have the right to considerate, Retrospective (post service) Appeal is a request respectful treatment at all times and under to change an adverse determination that the all circumstances with recognition of their Plan must approve in whole or in part of for care personal dignity. or services already received. A determination will be sent in writing or electronically within 60 3. Members have the right to be interviewed and calendar days of receipt of the appeal (30 calendar examined in surroundings designed to assure days for Iowa commercial, North Dakota elite1 reasonable visual and auditory privacy. and Minnesota plans) to the member or their 4. Members have the right to request and receive representative and/or any practitioner involved in a copy of medical records in the possession of the appeal. For North Dakota Medicaid Expansion the Plan and to request that they be amended members the time frame is 45 days. or corrected. 5. Members have the right, but are not required, The filing deadline for appeals can be made to select a Primary Care Physician (PCP) of within 180 days from notification of the adverse their choice. If a member is dissatisfied for any determination (there is no filing deadline in reason with the PCP initially chosen, he/she Minnesota). For North Dakota Medicaid Expansion has the right to choose another PCP. members, appeals can be made within 30 days from notification of the adverse determination. 6. Members have the right to expect For more information or questions about the communications and other records pertaining complaint or appeals process, see the policy or to their care, including the source of payment 83 for treatment, to be treated as confidential in 15. Members have the right to receive information accordance with the guidelines established in about the organization, its services, applicable South Dakota, North Dakota, and its Providers and Members’ rights and Iowa law. responsibilities, in accordance to 7. Members have the right to know the identity 42 CFR §438.10. and professional status of individuals 16. Members have the right to make providing service to them and to know which recommendations regarding the organization’s physician or other practitioner is primarily Member’s rights and responsibilities policies. responsible for their individual care. Members 17. Members have the right to be free from any also have the right to receive information form of restraint or seclusion used as a about our clinical guidelines and protocols. means of coercion, discipline, convenience, 8. Members have the right to a candid or retaliation, or the use of restraints and discussion with the practitioner(s) and/ seclusion. or Provider(s) responsible for coordinating 18. North Dakota Medicaid Expansion Members appropriate or medically necessary treatment have the right to be free to exercise all rights options for their conditions in a way that and that by exercising those rights; they shall is understandable, regardless of cost or not be adversely treated by the State, the Plan, benefit coverage for those treatment options. and/or its participating Providers. Members also have the right to participate with practitioners and/or Providers in decision-making regarding their treatment 7.3.2 Minnesota Member Rights: plan. In accordance with the Minnesota Department of 9. Members have the right to give informed Health, and the National Committee for Quality consent before the start of any procedure or Assurance (NCQA), you have certain rights as treatment. member of Sanford Health Plan of Minnesota, 10. When Members do not speak or understand including the following: the predominant language of the community, the Plan will make its best efforts to access an 1. COVERED SERVICES. These are network interpreter. The Plan has the responsibility to services provided by participating Sanford make reasonable efforts to access a treatment Health Plan network providers or authorized clinician that is able to communicate with by those providers. Your Policy fully defines the Member. what services are covered and described 11. Members have the right to receive printed procedures you must follow to obtain materials that describe important information coverage. about the Plan in a format that is easy to 2. PROVIDERS. Enrolling with Sanford Health understand and read. Plan does not guarantee services by a 12. Members have the right to a clear grievance particular provider on the list of network and appeal process for complaints and providers. When a provider is no longer part comments and to have their issues resolved in of the Sanford Health Plan network, you a timely manner. must choose amount from remaining Sanford Health Plan network providers. 13. Members have the right to appeal any decision regarding medical necessity made by the Plan 3. EMERGENCY SERVICES. Emergency services and its Providers. from providers outside the Sanford Health Plan network will be covered only if proper procedures are followed. Read this Policy 14. Members have the right to terminate coverage for the procedure, benefits and limitations under the Plan, in accordance with applicable associated with emergency care from Sanford Employer and/or Plan guidelines. Health Plan network and non-Sanford Health Plan network providers. 84 4. EXCLUSIONS. Certain service or medical individual health maintenance contract falling supplies are not covered. Read this Policy for a due after the first premium during which detailed explanation of all exclusions. period the contract shall continue in force. 5. CANCELLATION. Your coverage may be 5. Medicare enrollees have the right to canceled by you or Sanford Health Plan only voluntarily disenroll from the health under certain conditions. Read your Policy for maintenance organization and the right not the reasons for cancellation of coverage. to be requested or encouraged to disenroll 6. NEWBORN COVERAGE. A newborn infant is except in circumstances specified in federal covered from birth. Sanford Health Plan will law. not automatically know of the newborn’s birth 6. Medicare enrollees have the right to a clear or that you would like coverage under this description of nursing home and home care Plan. You should notify Sanford Health Plan benefits covered by the health maintenance of the newborn’s birth and that you would like organization. coverage. If your Policy requires an additional payment for each dependent, Sanford Heath 7.4 Member Responsibilities for Minnesota, Plan is entitled to all enrollment payments North Dakota, Iowa, and South Dakota due from the time of the infant’s birth until the time you notify the Plan of the birth. Sanford Each Member (or the Member’s parent, legal Health Plan may withhold payment of any guardian or other representative if the Member health benefits for the newborn infant until any is a minor or incapacitated) is responsible for enrollment payment you owe is paid. cooperating with those providing Health Care 7. PRESCRIPTION DRUGS AND MEDICAL Services to the Member, and shall have the EQUIPMENT. Enrolling with Sanford Health following responsibilities: Plan does neither guarantees that any particular prescription drug will be available 1. Members have the responsibility to provide, nor that any particular piece of medical to the best of their knowledge, accurate equipment will be available, even if the drug and complete information about present or equipment is available at the start of the complaints, past illnesses, hospitalizations, Policy year. medications, and other matters relating to their health. They have the responsibility to ENROLLEE BILL OF RIGHTS report unexpected changes in their condition (Minnesota Only) to the responsible practitioner. Members are responsible for verbalizing whether they 1. Enrollees have the right to be informed of clearly comprehend a contemplated course of health problems, and to receive information action and what is expected of them. regarding treatment alternatives and risks which is sufficient to assure informed choice. 2. Members are responsible for carrying their Plan ID cards with them, and for having 2. Enrollees have the right to refuse treatment, member identification numbers available and the right to privacy of medical and when telephoning or contacting the Plan, or financial records maintained by the health when seeking health care services. maintenance organization and its health care providers, in accordance with existing law. 3. Members are responsible for following all 3. Enrollees have the right to file a complaint access and availability procedures. with the health maintenance organization and the commissioner of health and the right to 4. Members are responsible for seeking initiate a legal proceeding when experiencing emergency care at a Plan participating a problem with the health maintenance emergency facility whenever possible. In organization or its health care providers. the event an ambulance is used, Members are encouraged to direct the ambulance to 4. Enrollees have the right to a grace period of 31 the nearest participating emergency facility days for the payment of each premium for an 85 unless the condition is so severe that you 9. Commercial Members are responsible for must use the nearest emergency facility. notifying the Plan through their employer State law in North Dakota, Iowa, and South within thirty (30) days if they change their Dakota requires that the ambulance transport name, address, or telephone number. you to the hospital of your choice unless that Medicaid Expansion Members are responsible transport puts you at serious risk. for notifying the North Dakota Department of 5. Members are responsible for notifying the Human Services Division of Medical Services Plan of an emergency admission as soon as within ten (10) days at toll-free at reasonably possible and no later than forty- (844) 854-4825 | ND Relay TTY: (800) 366-6888 eight (48) hours (ten (10) days for North Dakota (toll-free) if they change their name, address, Medicaid Expansion members) after becoming or telephone number. NDPERS Members physically or mentally able to give notice. are responsible for notifying NDPERS within thirty-one (31) days if they change their name, 6. Members are responsible for keeping address, or telephone number. appointments and, when they are unable to do so for any reason, for notifying the responsible 10. Commercial Members are responsible for practitioner or the hospital. notifying their employer and/or the Plan of any changes of eligibility that may affect 7. Members are responsible for following their membership or access to services. The their treatment plan as recommended by employer is responsible for notifying the Plan. the Provider primarily responsible for their North Dakota Medicaid Expansion Members care. Members are also responsible for are responsible for notifying the North Dakota participating in developing mutually Department of Human Services Division of agreed-upon treatment goals, and to the Medical Services of any changes of eligibility degree possible, for understanding their that may affect their membership or access to health care conditions, including mental services. NDPERS Members are responsible health and/or substance use disorders. for notifying their employer of any changes of 8. Members are responsible for their actions eligibility that may affect their membership or if they refuse treatment or do not follow the access to services. NDPERS is responsible for Practitioner’s instructions. notifying the Plan.

86 Online Tools, Publications & Forms

Sanford Health Plan offers online tools to log on to your provider account using the User specifically designed to help you obtain the ID and Password you created upon setting up your information you need as quickly as possible. account.

8.1 mySanfordHealthPlan If you have any questions or need assistance with setting up an account, please contact Provider mySanfordHealthPlan is Sanford Health Plan’s Relations at (605) 328-6877 or (800) 601-5086. online benefits tool available to providers. You can also send an email to providerrelations@ Through this secure online tool, you have access sanfordhealth.org. to information 24/7. With mySanfordHealthPlan you will be able to: 8.2 Provider Directory

• View copay deductibles, coinsurance and You can access the provider directory on out-of-pocket totals for members our site sanfordhealthplan.com or through • Verify member eligibility and view covered mySanfordHealthPlan under Eligibility & Benefits: family member(s) • Submit medical and pharmacy prior • Go to sanfordhealthplan.com authorizations and online claim • Click on “Providers - Find a Provider” reconsiderations • Click on “Learn More” • Access the provider manual and policies • Access the member login section on the right • Check status of claims side of the page • Obtain copies of Explanation of Payments • Enter member ID and last name

To request a mySanfordHealthPlan account; follow these steps: 1. Go to sanfordhealthplan.com/providerlogin 2. Click on “CREATE AN ACCOUNT” 3. Enter all the required account information on the following screens, then click “Finish”

Your information will then be submitted to be reviewed for approval. Once your account has been approved you will receive an email from Sanford Health Plan. Afterward, you will be able

87 8.3 Forms 8.5 Provider Newsletters

For your convenience, you will find our The Provider Perspective and Fast Facts are forms posted outside the secure login of electronic newsletters for providers and their mySanfordHealthPlan for providers. Some office staff. With each newsletter, we share of our commonly used forms include: Claim information about a variety of topics to keep Reconsideration Form, credentialing applications you up-to-date. To see past issues or to sign up for providers, Provider Information Update/ to receive the newsletter if you currently don’t ChangeForm, Health Management Referral Form receive it, click here. and more. To access a form, click here.

8.4 Sanford Health Plan ID Card & Benny Card

What do our ID cards look like? The answer depends on our products and services. We created a two page document that gives you a high level overview of our ID cards and basic information. To view or print a sample click here.

The Benny Card is a special purpose Visa® card that gives members an easy, automatic way to pay for eligible healthcare expenses. The card is given to members who sign up for a medical FSA (Flexible Spending Account), Health Reimbursement Account (HRA) or Health Savings Account (ASA). To view or print a sample click here.

88 Appendix

9.1 Glossary of Terms

Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Type of EDI Transaction: Health 270 (ANSI ASC X12)Electronic A Care Eligibility/Benefit Inquiry(- Eligibility/Benefits Request From Provider) A healthcare organization characterized by a payment and Type of EDI Transaction: Health care delivery model that seeks 271 (ANSI ASC X12)Electronic Accountable Care Organization Care Eligibility/Benefit Response to tie provider reimbursements Eligibility/Benefits Response (ACO) (FromHealth Plan) to quality metrics and reductions in the total cost of care for an assigned population of patients. 276 (ANSI ASC X12)Electronic Type of EDI Transaction: Health Care Claim Status Request Claims Status Request (From Provider) A professional who works with statistics and large numbers. In insurance, an actuary leads Actuary Type of EDI Transaction: Health analytics, underwriting, pricing, 277 (ANSI ASC X12)Electronic Care Claim Status Notification(- benefit design, and financial Claims Status Response From Health Plan) performance activities.

278 (ANSI ASC X12)Electronic Terms/Common Acronyms Definitions Type of EDI Transaction: Health Authorization Certification / Care Service Review Information Review Information Level of severity of an illness / Acuity / Bed patient care Type of EDI Transaction: Payroll 820 (ANSI ASC X12)Electronic Deducted and other group Acute / Sudden Onset Brief and severe Premium Payment Premium Payment for Insurance Products Short-term medical treatment; Acute Care / Urgent Care urgent medical care 834 (ANSI ASC X12)Electronic Type of EDI Transaction: Benefit Eligibility Enrollmentand Maintenance Set Lobbyist group for American American Dental Association dentists. Type of EDI Transaction: Health 835 (ANSI ASC X12)ERA (Elec- Care Claim Payment/Advice- Federal law protecting the rights Americans with Disability Act tronic Remittance Advice) Transaction Set (Electronic of individuals with disabilities. Remittance) Processing claims to determine Type of EDI Transaction: Health Adjudication pricing (allowances) and benefits 837 (ANSI ASC X12)Electronic Care Claim Transaction Set(In- (member liability) amounts. Claim (837P / 8371) bound / Outbound / Professional / Institutional) Reprocessing of a claim to make Adjustment a correction

89 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Routine activities that people Accepting payment from a health ADL (Activities of Daily Living) do every day without needing AOB (Assignment of Benefits) plan or federal program forser- assistance vices rendered to a patient

Written statement of a per- APC (Ambulatory Payment A type of outpatient prospective Advance Directive (Living Will / son’s wishes regarding medical Classification / OPPS) payment system Healthcare Power of Attorney) treatmentand how those wishes should be carried out Request by the member or Appeal provider to change an official Medical event or error that decision causes an injury to a patient as the resultof a medical interven- Adverse Event(Sentinel Event / tion rather than the underlying A phase I, phase II, phase III, or Never Event) medical condition. It represents phase IV clinical trial that iscon- an unintentional harm to a pa- ducted in relation to the preven- tient arising from any aspect of tion, detection, or treatment of healthcare management. cancer or other life-threatening disease or condition and is one of thefollowing: a. A federally Approved Clinical Trial The common phenomenon in funded or approved trial; b. A which healthy people choose not clinical trial conducted under Adverse Selection to insure and a disproportionate an FDA investigational new drug number of unhealthy people application; or c. A drug trial that enroll is exempt from the requirement of an FDA investigational new drug application. Affordable Care Act (ACA / Enacted to increase quality and PPACA) affordability of health insurance Used for pharmacy reimbursement/allowance calculation - av- Person who is employed by ASP (Average Sales Price) erage price at which a particular the broker, who works with the product or commodity is sold member, to find an insurance Agent / Insurance Agent across channels or markets plan that fits their needs to find an insurance plan that fits their needs. Assistant at Surgery / Assis- Defined as a physician or allied health practitioner who activel- tant Surgeon / Surgical Tech yassists the operating surgeon Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted Authorization / Referral / Prior Agreement to allow a member to ALOS (Average Length-of- from the date of admission to Notification / Prior Authori- access a specified service Stay) the date of discharge by the total zation number of discharges (including deaths) in all hospitals during a given year. A person to whom a covered person has given express writtenconsent to represent the AMA (American Medical Asso- Physician lobbyist group Member, a person authorized ciation) by law to provide substituted consent for a Member, a family member of the Member or the Vehicle for transportation to Ambulance Member’s treating health care provide for medical services Authorized RepresentativeAu- professional if the Member is unable to provide consent, or a thorized Representative Medical care provided on an health care professional if the Ambulatory/Outpatient outpatient basis (clinic/officeor Member’s Plan requires that a hospital outpatient department) request for a benefit under the plan be initiated by the health care professional. For any Ur- AMP (Average Manufacturer Average price paid by wholesal- gent Care Request, the term in- ers to manufacturers for drugs Price) cludes a health care professional distributed to retail pharmacies. with knowledge of the Member’s medical condition. Providers who provide neces- Ancillary Provider sary services within the network Claims process automatically of physicians Auto-Adjudication (Rate) / AA without pending; often im- provesefficiency and reduces / AAR expenses required for manual ANSI (American NationalStan- Format for transmitting industry standardized electronic informa- claims dards Institute) tion and forms

90 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Conditions that could reasonably Capitation Payment arrangement that pays have been prevented through a physician or group of physician- application of evidence-based sa set amount for each enrolled guidelines. These conditions are person assigned to them. not present on admission, but Avoidable Hospital Conditions present during the course of the stay.Participating Providers are Carrier (Health Plan) A company that creates and man- not permitted to bill the Plan or ages insurance products; control Members forservices related to underwriting, claims, pricing and Avoidable Hospital Conditions. overall guidance of the company.

Requires managed care plans Carve-Out A specifically defined benefit or to accept any qualified provider group of benefits in a plan. AWP (Any Willing Provider / who iswilling to accept the terms and conditions of a managed Average Wholesale Price) careplan / Pricing for pharma- Case Management (CM) A coordinated set of activities ceutical reimbursement/allow- conducted for individual Member ances management of chronic, serious, complicated, protracted, or other Laws that require managed care health conditions. organizations to grant network AWPL (Any Willing Provider participation to health care Laws) Case Rate A pricing method in which a flat providers willing to join and meet amount, often a per diem rate, the network requirements covers a defined group of procedures and services B Category II CPT Code Codes that describe clinical Balance Billing (Also see The practice of a healthcare components usually included in UC&R) provider billing a patient for the evaluation and management or difference between what the pa- clinical services tient’s health insurance chooses to reimburse and what the provider chooses to charge Category Ill CPT Code A temporary set of codes for emerging technologies, services, andprocedures Bilateral Procedure Procedures that are performed on both sides of the body during thesame procedure. CDC (Centers for Disease Government organization that Control) manages infectious disease pro- tocol and guidelines Brand Name Drug A drug that has a trade name and is protected by a patent (CDHP) Consumer-Directed A tier of health plans that allow Health Plan consumers to manage medical C expenses using HSAs, HRAs, or similar payment methods Cafeteria Plan Health plan where members have the option to choose betweendif- (CDT) Current Dental termi- Code set for reporting dental ferent types of benefits. nology services and procedures

(CAH) Critical Access Hospital A rural hospital (25 beds or less) Certificate ofCreditable Cover- Document that outlines the dates designated by CMS as a facility that is at least 35 miles from age (COC) of coverage for the member another acute hospital or CAH; throughtheir insurance carrier. receivescost-based reimbursement from CMS. Certification Certification is a determination by the Plan that a request for a ben- CAHPS (Consumer Assessment The CAHPS Health Plan Survey is efit has been reviewed and, based ofHealthcare Providers and a tool for collecting standardized on the information provided, Systems) information on enrollees’ experi- satisfies the Plan’s requirements ences with health plans and their for medical necessity, appropri- services ateness, health care setting, level of care, and effectiveness. Calendar Year A period of one year which starts on January 1st and ends Decem- ber 31st. Chemical Dependency / Sub- Addiction to a mood or mind stance Abuse/ Chem Dep / SUD altering drug / CD

91 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

CHIP / SCHIP Low-cost health insurance pro- Coordination ofBenefits (COB) Ensures a person with multiple gram designed for children of insurance policies isn’t compen- families whose income level was sated more than once too high to qualify for Medicaid.

Copay An amount that a Member must Chronic Disease A long-lasting condition that can pay at the time the Member be controlled but not cured receives a Covered Service.

(CHS) Contract Health Services Regulated under IHS, CHS is a CORF (Comprehensive Outpa- A medical facility that provides secondary program formedical/ tient Rehabilitation Facility), outpatient diagnostic, therapeu- dental care provided away from an Outpatient Rehab tic, and restorative services for IHS or tribal health the rehabilitation of your injury, disability, or sickness. Clinical Criteria Guidelines that provide recommendations for internal medicine physicians treating patients with Cosmetic Involving or relating to treatment certain aliments intended to restore or improve theperson’s appearance. Clinical Trial Research studies that test how well new medical approaches Cost Sharing Costs that a member is expected work with patients to pay as part of their plan

(CMS)Centers for Medicare and Government organization that Coverage (CVG) Policy that covers the insured in Medicaid administers Medicare, Medicaid,- the event of an unforeseen event CHIP, and parts of the Affordable Care Act (ACA) Coverage Gap Time between insurance coverage when a patient is not covered. CMS-1500 / AKA HCFA-1500 The standard claim form for professional or outpatient claims. Covered Services Those Health Care Services to which a Member is entitled under COBRA A continuation of healthcare cov- the terms of their Contract. erage for a member who leaves their employer. CPT Procedure Code /Current The code set that describes Procedure Terminology medical, surgical, and diagnos- Coinsurance The percentage of charges to be tic services and is designed to paid by a Member for Covered- communicate uniform information Services after the Deductible has about these services and proce- been met. dures among physicians, coders, patients, and payers for adminis- Concurrent Review Concurrent Review is Utilization trative, financial, and analytical Review for an extension ofprevi- ously approved, ongoing course Credentialing The process of establishing quali- of treatment over a period of fications of licensed professionals time or number of treatments and assessing their background. typically associated with Hospital Inpatient care, including care at Creditable Coverage Benefits or coverage provided a Residential Treatment Facility, under: a. Medicare or Medicaid; and ongoing outpatient services, b. An employer-based health in- including ambulatory care. surance plan or health benefit arrangement that provides benefits similar to or exceeding benefits [This] Contract or The Policy, including all attach- provided under a health bene- [The] Contract ments, the Group’s application, fit plan; c. An individual health theapplications of the Subscrib- insurance policy; d. Chapter 55 ers and the Health Maintenance of Title10, United States Code; e. Contract. A medical care program of the Indian Health Service or of a tribal organization; f. A state health Convalescent Care / Rehab / A range of health services benefits risk pool; g. A health plan Post-Op designed to help people recover offered under Chapter 89 ofTitle fromserious illness, surgery or 5, United States Code; h. A public injury health plan; i. A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504) (e));j. College plan; or k. A short- term limited-duration policy. 92 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

D Dual-Eligible Patient is eligible for both Medi- care and Medicaid Deductible The amount that a Member must pay each Calendar Year before the Durable Medical Equipment Any medical equipment used in Plan will pay benefits for Covered (DME) the home to aid in a betterquality Services. of living

Dependent The Spouse and any Dependent E Child of a Subscriber.

(EBSA) Employee Benefits An agency within the U.S. Dependent Child a. A Subscriber’s biological Security Administration Department of labor; provides child;A child lawfully adopted by information concerning rights the Subscriber or in the process under COBRA ofbeing adopted, from the date of placement;A stepchild of the (EDI) Electronic Date Inter- Transfer of data from one comput- Subscriber; orA foster child or change er system to another by standard- any other child for whom the ized message formatting Subscriber has been granted legal custody. Efficacy / Effectiveness Determination that a particular course of treatment is effective in DHS (Department of Human Agencies tasked with protecting managing a health condition Services, HHS (Federal)) the health of all Americans and- providing essential health services Elective Related to an elective procedure; not medically necessary Diagnosis (DX) Identification of an illness or other problem by examination ofthe Eligible Dependent Any “Dependent” who meets the symptoms specific eligibility requirements of the Plan under applicable State Disallowed Amount The difference between the actual and Federal laws and rules. amount of the procedure andthe amount agreed upon by the insur- Eligible Group Member Any Group Member who meets the ance company. specific eligibility requirements of the Group’s Plan. Discount Reduction to the prices of services; usually provided when Emergency Medical Condition Sudden and unexpected onset of seeing an in network provider a health condition that requires immediate medical attention, if failure to provide medical Disease Management A system of coordinated health attention would result in serious care interventions and commu- impairment to bodily functions nications for defined patient popu- or serious dysfunction of a bodily lations with conditions where self- organ or part or would place care efforts can be implemented. the person’s health in serious jeopardy. DOI (Department of Insurance) State departments that regulate insurance products and agents. EMR (EHR / Electronic Medical Digital version of a paper chart in Record /Electronic Health a clinician’s office DOL (Department of Labor) U.S. or State Department of Labor Record)

Domiciliary Care (Dom Care) A supervised living arrangement Endodontic Dentistry specialty concerned with in a home-like environment the study and treatment of the for adults who are unable to live dental pulp alone because of age-related impairments or physical, mental or visual disabilities. (EOB) Explanation of Benefits A statement sent by a health insurance company to covered in- dividualsexplaining what medical DOS (Date of Service) Date when services were rendered services were paid

DRG (Diagnostically-Related System used to classify hospital Grouping) cases

93 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

EOP (Explanation of Payment Report that accompanies claims Experimental or Investigational Health Care Services where the / RA) which provides a detailed report Services Health Care Service in question on how they were paid, denied, or either:a. is not recognized in ac- adjusted cordance with generally accepted medical standards as being safe ePrescribing / Electronic Pre- Allows the physician and other and effective for treatment of the scribing medical practitioners to write condition in question, regardless and sendprescriptions to partici- of whether the service is autho- pating pharmacies electronically rized by law or used in testing or other studies; or b. Requires approval by any governmental au- (ERA) Electronic Remittance ANSI transaction for claim pay- thority and such approval has not Advice ment I remittance. been granted prior to the service being rendered. ERISA (Employee Retirement Protects the assets of Americans Income Security Act) so that funds placed in retirement plansduring which the person F works will be available Facility An institution providing Health Care Services or a health care ESRD (End-Stage Renal Dis- Failure of the renal system (kid- setting, including Hospitals and ease) neys) other licensed inpatient centers, ambulatory surgical or treatment Essential Health Benefits (EHB) Based on 10 benefits that are centers, skilled nursing centers, covered across the board: ER, Residential Treatment Facili- prescription, inpatient/outpatient, ties, diagnostic, laboratory, and therapies, labs, preventative, imaging centers, and rehabilita- pediatric, prenatal, mental health/ tion, and other therapeutic health substance abuse settings.

Exchange / Marketplace, HIX, State or federal marketplace for Fee Schedule A complete listing of fees used by healthcare.gov the purchasing of health insur- Medicare to pay doctors or other ance for individuals and small providers/suppliers groups Fee-For-Service Comprehensive listing of fee Exclusion Not covered maximums is used to reimburse a physician or providers based on fee-for-service basis Expedited Appeal An expedited review involving Urgent Care Requests for Adverse Determinations of Prospective FEHBP (Federal Employees Consumer driven and high de- (Pre-service) or Concurrent Health Benefits Program) ductible plans that offer cat- Reviews will be utilized if the astrophic risk protection with Member, or Practitioner and/or higher deductibles, health savings Provider acting on behalf of the accounts, and lower premiums, or Member, believes that an expedit- Fee-for-Service plans, PPO/HMO ed determination is warranted plans

Experimental Refers to the status of a drug, Fiduciary A trustee; person who holds legal service, medical treatment or or ethical relationship of trust procedure that currently doesn’t between him/herself and one or present any credible evidence for more parties treatment or diagnosis. Flexible Spending Account Employee benefit program Experimental Drugs Medicinal product that has not yet (FSA) that allows a member to set received approval from govern- asidemoney for certain health mental regulatory authorities for care needs routine use

Form 1099 Tax form that reports the year-end summary of all-employee compensation

Form W9 Form used by the provider and is used to verify the taxpayeridenti- fication

94 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Formulary An official list of medications that H may be prescribed; coveredpre- scribed medicines Habilitative Services Health care services that help a person keep, learn or improve FQHC (Federally Qualified A reimbursement designation skills and functioning for daily Health Centers for several health programs; living community-based organization that provides care to persons of all ages regardless of their ability HCFA (The Health Care Finance Federal agency that administers to pay. Administration) the Medicare program and works in partnership to administer Med- icaid, SCHIP, and health insurance Fully-Funded / Fully Insured Employer pays the premium of the portability standards, such as health coverage HIPAA.

G HCPCS Procedure Code /“Hix- A set of health care procedure Pix”/ Healthcare CommonPro- codes based on Current Proce- cedure Coding System dural Terminology (CPT). Gatekeeper HMO that restricts access to specialists or out of networkproviders using a referral process. HDHP (High Deductible Health Plan that consists of a high Plan) deductible.

Generic Drug Drug product that is comparable to a brand drug product Healthcare Power of Attorney Becomes active when a person is (POA) unable to make decisions orcon- sciously communicate intentions Global Surgery Surgery and usual pre and regarding treatments post-operative work will be billed as a global package; global surgery fee Health Care Services Services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, GPCI (Geographic Pricing Cost Categories used by Medicare to injury or disease Index) determine allowable payment amounts for medical procedures HEDIS (Healthcare Effective- A tool used by a member’s health ness Data and Information Set) plan to measure performanceon GPO (Group Purchasing Orga- Used by groups of businesses to important dimensions of care and nization) obtain discounts based on their- service collective buying power

HHS (Health and Human Protects the health of all Amer- Grandfathered (GF) A provision in which an old rule Services) icans and provides essential continues to apply to someexisting humanservices for the general situations, while a new rule will public apply to all future cases

HIPAA (Health Insurance Protects the privacy of individually [The] Group The entity that sponsors this identifiable health information; health maintenance agreement as Portability and Accountability sets national standards for the permitted by SDCL-58-41 under Act of 1996) security of electronic protected which the Group Member is eligi- health information. ble and applied for this Contract.

HIPAA 5010 (ANSI ASC X12) New standard that regulates the Group Health Plan Employee benefit plan; main- electronic submission of specifi- tained by the employer number chealth care transactions (TIN)

HMO (Health Maintenance Organization that provides or Group Member Any employee, sole proprietor, arranges managed care for health partner, director, officer or Mem- Organization) insurance ber of the Group.

Home Health Care Care that is provided within a Guaranteed Issue Portion of PPACA that states member’s home in lieu of com- individuals can not be denied bined or anticipated hospitaliza- insurancecoverage tion

95 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Home Infusion Involves the administration of ICD-10 PCS /Procedure Coding Responsible for maintaining the intravenous (IV) medication, such System inpatient procedure code set; will as antibiotics and chemotherapy replace ICD-9-PCS

Hospice End-of-life care ICD-9 CM (International Statis- The official system for assigning tical Classification of Diseases, codes to diagnoses and proce- Clinical Modification) Hospital A short-term, acute care, duly li- dures censed institution that is primarily engaged in providing inpatient ICD-9 PCS (Procedure Coding Responsible for maintaining the diagnostic and therapeutic ser- System) inpatient procedure code set vices for the diagnosis, treatment, and care of injured and sick persons by or under the supervision IDS (Integrated Delivery Sys- A network of health care organiza- of Physicians. It has organized tem) tions under one parent company departments of medicine and/ or major surgery and provides 24-hour nursing service by or IHS (Indian Health Services) Operating division within HHS that under the supervision of regis- is responsible for providing med- tered nurses. The term “Hospital” ical and public health services to specifically excludes rest homes, members of federally recognized places that are primarily for the Tribes and Alaska Natives care of convalescents, nursing homes, skilled nursing facili- Implantable Device that is surgically implanted ties, Residential Care Facilities, custodial care homes, inter- in the patient, usually toprovide mediate care facilities, health medical treatment. resorts, clinics, Physician’s offices, private homes, Ambula- Indemnity / IND, Fee for service A health care plan where the tory Surgical Centers, residential member can see any provider or transitional living centers, or similar facilities. (nonetwork), and is reimbursed a set amount or percentage Hospitalization A stay as an inpatient in a Hospi- tal. Each “day” of Hospitalization In-Network Benefit Level The upper level of benefits includes a stay for which a charge provided by Sanford Health Plan, is customarily made. Benefits as defined in the Summary of may not be restricted in a way Benefits and Coverage, when a that is based upon the number of Member seeks services from a hours that the Member stays in Participating Practitioner and/or the Hospital. Provider designated by Sanford Health Plan, in its sole discretion, HRA (Health Reimbursement Employer funded, health benefit as part of this Certificate of Account) plans that reimburse employ- Coverage’s defined network. eesfor out-of-pocket medical expenses Inpatient (INPT) A patient who stays in the hospital while under treatment & incurs HSA (Health Savings Account) Medical savings account avail- roomand board charges able to taxpayers enrolled inhigh deductible policy. Institutional Service / Hospital Service that was provided at a Services facility I Intensive Outpatient Program Treatment service and support Iatrogenic Condition / Illness or injury because of mis- (IOP) program used primarily to treat Nosocomial Condition takes made in medical treatment, mental illness and chemical such as surgical mistakes, pre- dependency scribing or dispensing the wrong medication or poor hand writing IPPS (Inpatient Prospective Payment system with catego- resulting in a treatment error. Payment System) rizes cases into a diagnosis-re- latedgroup (DRG). The base IBNR Expenses / Incurred but Term for the collective claims that payment rate is divided into not Reported, future will be filed in the future forcur- labor-related andnon labor share, rent medical conditions which is then adjusted by wage indexapplicable to the area where ICD-10 CM / International 10th revision of ICD; will eventual- the hospital is located. Statistical Classification of ly replace ICD-9 Diseases

96 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

L Marketplace / Exchange Also known as the Health Insur- ance Exchange; where people without health insurance can Letter of Medical Necessity Documentation that is submitted search for insurance options and (LOMN) by a provider who is requesting- purchase an insurance plan. certain services for the patient. Maxillofacial Refers to the head, neck, face Lifetime Maximum The maximum dollar amount and jaw that will be paid on for a member’s health plan Maximum Allowed Amount The amount established by Sanford Health Plan using various Limited Cost Sharing (LCS) A plan available to members of methodologies for Covered federally recognized tribes, those Services and supplies. Sanford who income is above 30% of federal poverty line which is available Health Plan’s Maximum Allowed through the Marketplace. Amount is the lesser of: a) the amount charged for a Covered Service or supply; or Living Will /Advance Health Legal document in which a person b)inside Sanford Health Plan’s Care Directive specifies actions that should be taken for their health when they Service Area, negotiated are no longer capable to make schedules of payment developed that decision for themselves. by Sanford Health Plan, which are accepted by Participating Locum Tenens Written statement of a person’s Practitioner and/or Providers; or wishes regarding medicaltreat- c) outside of Sanford Health ment and how those wishes Plan’s Service Area, using current should be carried out publicly available data adjusted for geographical differences where applicable: Long-Term Residential Care The provision of long-term i.Fees typically reimbursed to diagnostic or therapeutic services (i.e., assistance or supervision providers for same or similar in managing basic day-to-day professionals; or activities and responsibilities) to j.Costs for Facilities providing the Members with physical, mental same or similar services, plus a health and/or substance use margin factor. disorders. Care may be provided in a long-term residential environment known as a transitional MCO (Managed Care Organiza- System of health care in which living Facility; on an individual, tion, Managed Care) patients agree to visit only certain group, and/or family basis; gen- doctors and hospitals erally provided for persons with a lifelong disabling condition(s) Medically Necessary /Medical Health Care Services that are that prevents independent living Necessity appropriate and necessary as for an indefinite amount of time. determined by any Participat- ing Provider, in terms or type, LOS (Length-of-Stay) Duration of a single episode of frequency, level, setting, and hospitalization duration, according to the Mem- ber’s diagnosis or condition, and diagnostic testing and Preventive M services. Medically Necessary care must be consistent with generally accepted standards of Maintenance Care Treatment provided to a Mem- medical practice as recognized by ber whose condition/progress the Plan, as determined by health has ceased improvement or could care Practitioner and/or Provid- reasonably be expected to be man- ers in the same or similar general aged without the skills of a Practi- specialty as typically manages the tioner and/or Provider. condition, procedure, or treatment at issue; and a. help restore or Managed Care (MC, MCO) System of health care in which maintain the Members health; patients agree to visit only certain or b. Prevent deterioration of the doctors and hospitals Member’s condition; or c. Prevent the reasonably likely onset of a health problem or detect an incip- Mandated Benefit A benefit that is legally required ient problem; or d. Not considered by state or federal law Experimental or Investigative

97 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Medicare Advantage - SNP / Limited membership to people Medicare Part A Covers hospital care, skilled nurs- Special Needs Plan with specific diseases to tailor ing facility care, Hospice, home their benefits healthservices.

Medicaid Social health care program for Medicare Part B Covers for medically necessary families and individuals with low services and supplies, preventa- income and limited resources tive services, mental health, second opinion, and limited outpatient Medicaid Expansion Social health care program for prescription drugs. families and individuals with low income and limited resources for Medicare Part D Medicare prescription drug members who reside in ND and benefit are 19 and older

Medicare SELECT Type of Medigap plan that works Medical Home A concept that focuses on the like a HMO (in network) care of children with special health careneeds Medicare Summary No- Notice that shows all services tice(MSN) (similar to an EOB) and supplies that providers and Medical Loss Ratio / Loss Ratio A basic financial measurement suppliers have billed to Medicare / MLR used in the Affordable Care Act within a 3 month period, and what toencourage health plans to pro- Medicare paid. vide value to enrollees Medicare Supplement / Medi- Sold by private insurance compa- Medical Management A collaborative process that facil- gap nies; can help pay for health care itates recommended treatment coststhat Medicare doesn’t cover. plans to assure the appropriate medical care is provided to disabled, ill or injured individuals Member An individual who belongs to an entity Medical Necessity Defined as accepted health care services and supplies provided by Member (Patient)Liability The dollar amount that an insured health care entities with the appli- is legally obligated to pay forser- cable standard of care. vices rendered by a provider.

Medically-Fragile Defined as a chronic physical con- Mental Health / Behavioral Includes emotional, psychological, dition, which results in prolonged Health and social well-being dependency on medical care for which daily skilled intervention is medically necessary Mental Health and Substan- Health Care Services for disor- ceUse Disorder Services ders specified in the Diagnostic and Statistical Manual of Mental Medicare Social insurance program; pro- Disorders (DSM), the American vides health insurance to mem- Society of Addiction Medicine bers who are 65 or older, those Criteria (ASAM Criteria), and who are disabled, or have ESRD theInternational Classification of Diseases (ICD), current editions. Medicare Advantage / Medicare Covers for medically necessary Also referred to as behavioral Part C / Medicare Replacement care that members receive fromhealth, psychiatric, chemical de- / MA pendency, substance abuse, and/ nearly any hospital or doctor who or addiction services. accepts Medicare.

MHPA (Mental Health Parity Requires that annual or lifetime Medicare Advantage / Health- Allows members to utilize provid- Act) dollar limits on mental health Maintenance Organization ers or hospitals that are in their- benefits be no lower than any (HMO) provider list; will need a referral to such dollar limits for medical see providers that are OON benefits offeredby a group health plan. Medicare Cost Plan Offered in certain areas; members can join if they are only (MIPPA) Medicare Improve- Funding that is received to help enrolled inPart B, can go to an out ments for Patients and Provid- Medicare beneficiaries apply ers Act of network provider, can join and forMedicare Part D leave at any time. MMA (Managed Medical Assis- Medicaid program where patients tance) are managed by a provider or network organization

98 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

MOOP / OPM / MOP Maximum out of pocket; total Non-Participating Provider A Practitioner and/or Provider amount that the member will who does not have a contractual need to paybefore their health relationship with Sanford Health plan will pay at 100%. Plan, directly or indirectly, and not approved by Sanford Health Plan MSA (Medical Savings Account) A medical savings program for to provide Health Care Services self-employed individuals to seta- to Members with an expectation side tax-deferred money to pay for of receiving payment, other than medical expenses Coinsurance, Copays, or Deductibles, from Sanford Health Plan. MS-DRG WeightedFee Schedule System for the bundling of claims (DRG) for hospital services based ondi- agnosis, complications, length of NPI (National Identification number that is stay, and other factors. Provider Identifier) assigned to a provider or facility

Multiple Surgery Separate procedures performed Nursing Services Health Care Services which are by a single physician or physicians provided by a registered nurse in the same group practice on the (RN), licensed practical nurse same patient, at the same opera- (LPN), or other licensed nurse tive session, or on the same day. who is: (1) acting within the scope of that person’s license, N (2) authorized by a Provider, and (3) not a Member of the Member’s immediate family. NAIC (National Association US standard-setting and reg- ofInsurance Commissioners) ulatory support organization created and governed by the chief O insurance regulators from all states and US territories. Orthodontic Treatment of improper bites and crooked teeth Natural Teeth Teeth, which are whole and without impairment or periodontal disease, and are not in need of the Orthotics Specialty that focuses on the treatment provided for reasons design, manufacture, and applica- other than dental injury. tion oforthotics.

NCQA(National Committee for Leader in health care accredita- OTC (Over the Counter) Medicines sold directly to a Quality) tion; works to improve health care consumer without a prescription froma provider. NDI (National Drug Code) System that provides each drug with a unique product identifier Out-of-Network (OON) / ON / A Practitioner and/or Provider Non-Participation who does not have a contractual Network A group of two or more entities relationship with Sanford Health Plan, directly or indirectly, and not that are linked together approved by Sanford Health Plan to provide Health Care Services to Never Event Errors in medical care that are Members with an expectation of clearly identifiable, preventable, receiving payment, other than Co- insurance, Copays, or Deductibles, and serious in their consequences from Sanford Health Plan. for patients, and indicate a problem in the safety and credibility of a health care Facility. Participat- Out-of-Pocket Maximum The total Copay, Deductible and ing Providers are not permitted Amount Coinsurance Amounts for certain Covered Services that are a Mem- to bill the Plan or Members for ber’s responsibility each calendar services related to Never Events. year. When the Out-of-Pocket Maximum Amount is met, the Non-Covered Services Health Care Services that are Plan will pay 100% of the Reason- not part of benefits paid for able Costs for Covered Services. The Out-of-Pocket Maximum by the Plan. Amount resets on January 1 of each calendar year. Medical and Non-Grandfathered Refers to an old rule that no prescription drug Copay amounts longer applies to the policy apply toward the Out-of-Pocket Maximum Amount

99 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Outpatient (OTPT) One who received medical treat- Place of Service Type/ Office, Codes for the place of service are ment without being admitted to a outpatient, inpatient, urgent used for billing purposes todeter- hospital care, ER, lab, etc. mine how the patient’s healthcare plan will pay. P PMPM (Per Member Per Month) Capitation payment methodology Palliative Relieving pain or alleviating a problem without dealing with Podiatry Branch of medicine associated theunderlying cause. with foot, ankle and related

Participating Provider/PAR/ Practitioner, institution or Policy Decisions, plans and actions that Participating/Contracted organization or someone on their are undertaken to achievespecific behalf has signed a contract with health care goals the Plan or one of the Plan’s contracted vendors to provide Covered Services to Members Policyholder A person or group in whose name and, as a result of signing such an insurance policy is held contract, is a participating provider in the Plan’s Panel of Providers. POS (Place of Service) Defined by codes placed on health care claims which indicate the setting in which a service was Partial Hospitalization Program Also known as day treatment; provided to the member. A licensed or approved day or evening outpatient treatment program that includes the major PPO (Preferred Provider Orga- A managed care organization diagnostic, medical, psychiatric nization) of providers and facilities who and psychosocial rehabilitation have agreed with an insurer or treatment modalities designed third-party administrator to pro- for individuals with mental health vide health care at reduced rates and/or substance use disorders who require coordinated, Practitioner/Provider Someone who is qualified or reg- intensive,comprehensive and istered to practice medicine multi-disciplinary treatment with such programlasting a minimum of six (6) or more continuous Pre-Existing Condition (Pre-Ex) A medical condition that started hours per day. before the member’shealth insurance went into effect PBM Third party administrator of pre- (Pharmacy benefit manager) scription drug programs Premium The amount that the insured pays for health insurance PCP (Primary Care Provider) A specialist in Family Medicine, Internal Medicine, Obstetrics & Preventive A yearly exam that helps keep a Gynecology or Pediatrics who provides the first contact for a pa- member free of disease tient with an undiagnosed health concern and takes continuing Primary Carrier The first carrier that covers the responsibility for providing the insured; first payer patient’s comprehensive care.

Primary Payor Refers to who will pay first in Per Diem / Per Day Daily allowance for expenses regards to member’s claims

PHI Data that is protected under HI- Private Duty Nursing Nurses who provide private duty (Protected Health Information) PAA and must not be disclosed care by working one-on-one with whendiscussing a patient or individual clients member’s affairs Procedure Medical treatment or service PHO (Physician-Hospital A group formed by a hospital and Organization) its providers in order to con- Professional Service A service provided to a member of tractwith an MCO the health plan

Physician / MD, DO, PhD, DC, Professional who practices Prompt Payment Ensures that agencies pay ven- DPM medicine dors in a timely manner

100 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Prophylactic / Preventive Medication or a treatment Prudent Layperson Person with medical training designed and used to prevent a who exercises those qualities of disease from occurring attention, knowledge, intelligence and judgment. A standard for determining the need to visit the ER. Prospective Review Used in UM to review upcoming services QHP (Qualified Health Plan) A health plan certified by the Marketplace to meet new benefit Prosthetics An artificial limb and costsharing standards

Prosthodontic Dental prosthetics; area of den- Primary Payor Refers to who will pay first in tistry that focuses on dental regards to member’s claims

Prudent Layperson Person with medical training Qualifying Event A change in your life that can who exercises those qualities of make you eligible for a special attention, knowledge, intelligence enrollment period to enroll in and judgment. A standard for de- health coverage. termining the need to visit the ER.

Radiology Medical specialty that uses imag- QHP (Qualified Health Plan) A health plan certified by the ing to diagnose and treat diseases Marketplace to meet new benefit and injuries within the body and costsharing standards Reasonable Costs Those costs that do not exceed Primary Payor Refers to who will pay first in the lesser of: (a) negotiated regards to member’s claims schedules of payment developed by the Plan, which are accepted byParticipating Practitioners and/ Q or Providers or (b) the prevailing marketplace charges. Qualifying Event A change in your life that can make you eligible for a special Reconstructive The use of surgery to restore the enrollment period to enroll in form and function of the body health coverage.

Recoupment The use of surgery to restore the R form and function of the body

Radiology Medical specialty that uses imag- Reduced Payment Level The lower level of benefits ing to diagnose and treat diseases provided by The Plan, as defined and injuries within the body in the Summary of Benefits and Coverage, when a Member seeks Reasonable Costs Those costs that do not exceed services from a Participating or the lesser of: (a) negotiated Non-Participating Practitioner schedules of payment developed and/or Provider without Plan by the Plan, which are accepted certification or prior-authorization byParticipating Practitioners and/ when certification/prior-authori- or Providers or (b) the prevailing zation is required. marketplace charges. Rehabilitation To restore to good health or useful Prophylactic / Preventive Medication or a treatment life; through therapy designed and used to prevent a disease from occurring Reinsurance Insurance that is purchased by an insurance company from one Prospective Review Used in UM to review upcoming or more other insurance compa- services nies directly through a broker as a means of risk management Prosthetics An artificial limb Residential Care Refers to long-term care given to adults or children who stay in Prosthodontic Dental prosthetics; area of den- aresidential setting rather than tistry that focuses on dental their own home.

101 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Residential Treatment Facility An inpatient mental health or Routine Dental Yearly dental checkup substance use disorder treatment Facility that provides twenty-four (24) hour availability of quali- Routine Vision Yearly vision checkup fiedmedical staff for psychiatric, substance abuse, and other ther- RX (Prescription Drug) A measure of value used by apeutic and clinically informed Medicare as a reimbursement services to individuals whose im- formulafor physician services mediate treatment needs require a structured twenty-four (24) hour residential setting that provides S all required services on site. Services provided include, but are not limited to, multi-disciplinary Schedule of Benefits& Coverage Detailed, standard descriptions of evaluation, medication man- (SBC) a member’s health care benefits agement, individual, family and group therapy, substance abuse education/ counseling. Facilities Screening Used to identify an unrecognized must be under the direction of a disease in individualswithout board-eligible or certified psychi- signs or symptoms atrist, with appropriate staffing on-site at all times. If the Facility provides services to children and Secondary Carrier The second insurance carrier that adolescents, it must be under insures the patient the direction of a board-eligible or certified child psychiatrist or Self-Funded / Self-Insured A self-insurance arrangement general psychiatrist with experi- whereby an employer provides ence in the treatment of children. health or disability benefits to Hospital licensure is required if employees with its own funds the treatment is Hospital-based. The treatment Facility must be licensed by the state in which it SEP (Special Enrollment Period) A time outside of the open enroll- operates. ment period during which youand your family have a right to sign up Respite (Hospice) Type of care that focuses on for health coverage chronically ill or terminally ill patients,residential setting rather Service Area The area in which the member can than their own home. access providers; generallybased on the area where the member Retrospective Review A post treatment assessment of lives. services on a case-by-case basis after treatment has already been Service Charge The amount paid by the Group to provided. the Plan on a monthly basis for coverage for Members under this Revenue Code (REV Code) 3-digit numbers that are used on Contract hospital bills to indicate where the patient was receiving treat- Skilled Nursing (SNNF) Nursing Home ment

Specialty A branch in medical practice; Rider An additional provision that is further medical education added to the member’s policy

Specialty Care Scope of care for patients within Risk The potential of losing something a specific specialty (Ex. gastroen- of value terology)

Risk Adjustment An actuarial tool used to calibrate Specialty Drug High cost prescribed drug payments to health plans orother stakeholders based on the relative health of the at-risk

Risk Pool Practiced by insurance companies; come together to form a poolprovide a safety net against catastrophic risks.

102 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

Special Enrollment Period A time outside of the open SSA (Social Security Adminis- Social insurance program consist- enrollment period during which tration) ing of retirement, disability,and you and your family have a right survivor’s benefits. to sign up for health coverage. In theMarketplace, you qualify for a special enrollment period 60 Step Therapy The practice of beginning drug days following certain life events therapy for a medical condition- that involve a change in family with the most cost-effective and status (for example, marriage or safest drug therapy and progress- birth of a child) or loss of other es to other more costly therapies health coverage. Job-based plans must provide a special enrollment only if necessary period of 30 days. [This] State The State of South Dakota. Spouse An individual who is a Subscrib- er’s current lawful Spouse. Subrogation (SUBRO) The right for an insurer to pursue a third party that caused an insurance loss to the insured; SSA (Social Security Adminis- Social insurance program consist- means of recovering the amount tration) ing of retirement, disability,and of the claim paid to the insured survivor’s benefits. for the loss.

Step Therapy The practice of beginning drug Subscriber An Eligible Group Member who is therapy for a medical condition- enrolled in the Plan. A Subscriber with the most cost-effective and is also a Member. safest drug therapy and progress- es to other more costly therapies Summary ofPharmacy Benefits Document that outlines the cover- only if necessary age of prescription drugs

[This] State The State of South Dakota. Summary Plan Description Document that outlines the dates of coverage for the member- Subrogation (SUBRO) The right for an insurer to pursue through their insurance carrier. a third party that caused an insurance loss to the insured; means of recovering the amount T of the claim paid to the insured for the loss. Tax Identification Number / TIN An identifying number used to / EIN / Employer Identification identify a business entity Subscriber An Eligible Group Member who is Number enrolled in the Plan. A Subscriber is also a Member. Telemedicine / Telehealth The use of telecommunication and information technologies inorder Summary ofPharmacy Benefits Document that outlines the cover- to provide clinical health care at a age of prescription drugs distance.

Summary Plan Description Document that outlines the dates Tertiary Care Specialized consultative care; of coverage for the member- usually a referred provider through their insurance carrier. Third-Party Payer An institution or company that Tax Identification Number / TIN An identifying number used to provides reimbursement to / EIN / Employer Identification identify a business entity health careproviders for services Number rendered to a third party

Telemedicine / Telehealth The use of telecommunication and Tiered Co-paymentBenefits Prescription benefit; co-payments information technologies inorder are split into three tiers fornon- to provide clinical health care at a formulary, formulary and brand distance. name

Spouse An individual who is a Subscrib- Timely Filing (TF) The amount of time the provider’s current lawful Spouse. er has to submit a claim to the insurance plan for payment

103 Terms/Common Terms/Common Definitions Definitions Acronyms Acronyms

TMJ (Temporamandibular Joint) Associated with the jaw and sur- Utilization Management The evaluation of the medical rounding muscles of the face necessity, appropriateness, and efficiency of the use of health care services, procedures and facilities TPA (Third Party Administrator) Arrangement where a health plan under the provisions of the health administers various aspects of plan an insurance plan while the plan sponsor retains risk Utilization Review A set of formal techniques used by the Plan to monitor and Transitional Small Group Small groups who must transition evaluate the medical necessity, to QHPs under new ACA regula- appropriateness, and efficiency of tions Health Care Services and procedures including techniques such as ambulatory review, Prospec- Type of Bill Codes that are three digit codes tive (pre-service) Review, second located on a claim form that de- opinion,Certification, Concurrent scribes the type of bill a provider Review, Case Management, dis- is submitting to a payer charge planning, and retrospective (post-service) review. U W UB04 / Institutional / UB/UB92 Uniform instructional billing claim / Facility form used by hospitals, clinics, Waiting Period The period of time between when ambulatory surgery centers, etc. an action is requested or man- datedand when it occurs; period where insurance will not pay. Unbundling Charge for items or services separately rather than as a part of a package WHO (World Health Organiza- International group that directs tion) and coordinates international- Uninsured Patient who doesn’t have health health within the United Nations’ insurance system

Urgent Care (UC) Acute care; walk-in clinic focused Women’s Preventive Health Preventative, maternity and on the delivery of ambulatory (ACA) contraceptive services for wom- enthat are covered at 100% for non-grandfathered, ACA-com- Urgent Care Request Means a request for a health care service or course of pliant treatment with respect to which the time periods for making Workers’ Compensation (WC) / A form of insurance providing a non-Urgent Care Request Work Comp wage replacement and medical determination: 1. Could seriously benefits to employees injured jeopardize the life or health of the in the course of employment in Member or the ability of the Mem- exchange of mandatory relin- ber to regain maximum function, quishment based on a prudent layperson’s judgment; or 2. In the opinion of a Practitioner and/or Provider Write-off / Discount The reduction of value (provider with knowledge of the Member’s write off) medical condition, would subject the Member to severe pain that cannot be adequately managed Z without the health care service or treatment that is the subject of Zero-Cost Sharing (ZCS) A plan available to members the request. of federally recognized tribes and Alaska Native Claims Settle- Us/We Refers to Sanford Health Plan ment Act (ANCSA); no deductible, co-payments, or coinsurance Utilization / Use / Usage The “use” of; in regards to the use of benefits while controlling costs andmonitoring quality of care

104 9.2 Modifiers 26. Professional Component: Certain procedures are a combination of a physician component 22. Unusual Procedural Services: When the and a technical component. When the service(s) provided is greater than that usually physician component is reported separately, required for the listed procedure, it may be the service may be identified by adding the identified by adding modifier 22 to the usual modifier 26 to the usual procedure number. procedure number. A report may also be appropriate. 32. Mandated Services: Services related to mandated consultation and/or related services 23. Unusual Anesthesia: Occasionally, a (e.g., PRO, third party payer, governmental, procedure, which usually requires either no legislative or regulatory requirement) may anesthesia or local anesthesia, because of be identified by adding the modifier 32 to the unusual circumstances must be done under basic procedure. general anesthesia. This circumstance may be reported by adding the modifier 23 to the 47. Anesthesia by Surgeon: Regional or general procedure code of the basic service. anesthesia provided by the surgeon may be reported by adding the modifier 47 to the 24. Unrelated Evaluation and Management basic service. (This does not include local Service by the Same Physician During a anesthesia.) Note: Modifier 47 would not Postoperative Period: The physician may need be used as a modifier for the anesthesia to indicate that an evaluation and management procedures. service was performed during a postoperative period for a reason(s) unrelated to the 50. Bilateral Procedure: Unless otherwise original procedure. This circumstance may identified in the listings, bilateral procedures be reported by adding the modifier 24 to the that are performed at the same operative appropriate level of E/M service. session should be identified by adding the modifier 50 to the appropriate five digit code. 25. Significant, Separately Identifiable Evaluation and Management Service by the Same 51. Multiple Procedures: When multiple Physician on the Same Day of the Procedure procedures, other than E/M services, are or Other Service: The physician may need to performed at the same session by the indicate that on the day a procedure or service same provider, the primary procedure or identified by a CPT code was performed, the service may be reported as listed. The patient’s condition required a significant, additional procedure(s) or service(s) may separately identifiable E/M service above and be identified by appending the modifier beyond the other service provided or beyond 51 to the additional procedure or service the usual preoperative and postoperative code(s). Note: This modifier should not be care associated with the procedure that was appended to designated “add-on” codes. performed. The E/M service may be prompted by the symptom or condition for which the 52. Reduced Services: Under certain procedure and/or service was provided. As circumstances a service or procedure such, different diagnoses are not required for is partially reduced or eliminated at reporting of the E/M services on the same the physician’s discretion. Under these date. This circumstance may be reported by circumstances the service provided can be adding the modifier 25 to the appropriate level identified by its usual procedure number and of E/M service. Note: This modifier is not used the addition of the modifier 52, signifying to report an E/M service that resulted in a that the service is reduced. This provides decision to perform surgery. See modifier 57. a means of reporting reduced services without disturbing the identification of the

105 basic service. Note: For hospital outpatient 56. Preoperative Management Only: When one reporting of a previously scheduled procedure/ physician performed the preoperative care and service that is partially reduced or canceled as evaluation and another physician performed a result of extenuating circumstances or those the surgical procedure, the preoperative that threaten the well-being of the patient component may be identified by adding the prior to or after administration of anesthesia, modifier 56 to the usual procedure number. see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use). 57. Decision for Surgery: An evaluation and management service that resulted in the 53. Discontinued Procedure: Under certain initial decision to perform the surgery may circumstances, the physician may elect to be identified by adding the modifier 57 to terminate a surgical or diagnostic procedure. the appropriate level of E/M service. Due to extenuating circumstances or those that threaten the wellbeing of the 58. Staged or Related Procedure or Service by patient, it may be necessary to indicate the Same Physician during the Postoperative that a surgical or diagnostic procedure Period: The physician may need to indicate was started but discontinued. This that the performance of a procedure or circumstance may be reported by adding service during the postoperative period the modifier 53 to the code reported by the was: a) planned prospectively at the time physician for the discontinued procedure. of the original procedure (staged); b) more extensive than the original procedure; Note: This modifier is not used to report the or c) for therapy following a diagnostic elective cancellation of a procedure prior surgical procedure. This circumstance may to the patient’s anesthesia induction and/ be reported by adding the modifier 58 to or surgical preparation in the operating the staged or related procedure. Note: This suite. For outpatient hospital/ambulatory modifier is not used to report the treatment surgery center (ASC) reporting of a of a problem that requires a return to previously scheduled procedure/service that the operating room. See modifier 78. is partially reduced or canceled as a result of extenuating circumstances or those that 59. Distinct Procedural Service: Under certain threaten the wellbeing of the patient prior circumstances, the physician may need to to or after administration of anesthesia, indicate that a procedure or service was see modifiers 73 and 74 (see modifiers distinct or independent from other services approved for ASC hospital outpatient use). performed on the same day. Modifier 59 is used to identify procedures/services that 54. Surgical Care Only: When one physician are not normally reported together, but performs a surgical procedure and are appropriate under the circumstances. another provides preoperative and/ or This may represent a different session or postoperative management, surgical patient encounter, different procedure or services may be identified by adding the surgery, different site or organ system, modifier 54 to the usual procedure number. separate incision/excision, separate lesion, or separate injury (or area of injury in 55. Postoperative Management Only: When extensive injuries) not ordinarily encountered one physician performed the postoperative or performed on the same day by the same management and another physician performed physician. However, when another already the surgical procedure, the postoperative established modifier is appropriate it should component may be identified by adding the be used rather than modifier 59. Only if no modifier 55 to the usual procedure number. more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

106 62. Two Surgeons: When two surgeons work 76. Repeat Procedure by Same Physician: together as primary surgeons performing The physician may need to indicate that distinct part(s) of a procedure, each surgeon a procedure or service was repeated should report his/her distinct operative work subsequent to the original procedure by adding the modifier 62 to the procedure or service. This circumstance may be code and any associated add-on code(s) for reported by adding the modifier 76 to that procedure as long as both surgeons the repeated procedure/service. continue to work together as primary surgeons. Each surgeon should report the 77. Repeat Procedure by Another Physician: co-surgery once using the same procedure The physician may need to indicate that a code. If additional procedure(s) (including basic procedure or service performed by add-on procedure(s) are performed during another physician had to be repeated. This the same surgical session, separate code(s) situation may be reported by adding modifier may also be reported with the modifier 62 77 to the repeated procedure/service. added. Note: If a co-surgeon acts as an assistant in the performance of additional 78. Return to the Operating Room for a Related procedure(s) during the same surgical Procedure During the Postoperative Period: session, those services may be reported using The physician may need to indicate that separate procedure code(s) with the modifier another procedure was performed during the 80 or modifier 82 added, as appropriate. postoperative period of the initial procedure. When this subsequent procedure is related 63. Procedure Performed on Infants less to the first, and requires the use of the than 4 kg: Procedures performed on neonates operating room, it may be reported by adding and infants up to a present body weight of 4 kg the modifier 78 to the related procedure. (For may involve significantly increased complexity repeat procedures on the same day, see 76.) and physician work commonly associated with these patients. This circumstance 79. Unrelated Procedure or Service by the Same may be reported by adding the modifier Physician During the Postoperative Period: 63 to the procedure number. Note: Unless The physician may need to indicate that the otherwise designated, this modifier may only performance of a procedure or service during be appended to procedures/services listed the postoperative period was unrelated to the in the 20000-69999 code series. Modifier 63 original procedure. This circumstance may should not be appended to any CPT codes be reported by using the modifier 79. (For listed in the Evaluation and Management repeat procedures on the same day, see 76.) Services, Anesthesia, Radiology, Pathology/ Laboratory, or Medicine sections. 80. Assistant Surgeon: Surgical assistant services may be identified by adding the 66. Surgical Team: Under some circumstances, modifier 80 to the usual procedure number(s). highly complex procedures (requiring the concomitant services of several physicians, 81. Minimum Assistant Surgeon: Minimum often of different specialties, plus other highly surgical assistant services are skilled, specially trained personnel, various identified by adding the modifier 81 types of complex equipment) are carried to the usual procedure number. out under the “surgical team” concept. Such circumstances may be identified by each 82. Assistant Surgeon (when qualified resident participating physician with the addition surgeon not available): The unavailability of the modifier 66 to the basic procedure of a qualified resident surgeon is a number used for reporting services. prerequisite for use of modifier 82 appended to the usual procedure code number(s).

107 90. Reference (Outside) Laboratory: When Example: 00100-P4-53 laboratory procedures are performed by a party other than the treating or P1 A normal healthy patient reporting physician, the procedure may P2 A patient with mild systemic disease be identified by adding the modifier 90 P3 A patient with severe systemic disease to the usual procedure number. P4 A patient with severe systemic disease that is a constant threat to life 91. Repeat Clinical Diagnostic Laboratory Test: P5 A moribund patient who is not expected In the course of treatment of the patient, to survive without the operation it may be necessary to repeat the same P6 A declared brain-dead patient whose organs laboratory test on the same day to obtain are being removed for donor purposes subsequent (multiple) test results. Under these circumstances, the laboratory test CENTER (ASC) HOSPITAL OUTPATIENT USE performed can be identified by its usual procedure number and the addition of the CPT Level I Modifiers modifier 91. Note: This modifier may not be used when tests are rerun to confirm 25 Significant, Separately Identifiable initial results; due to testing problems Evaluation and Management Service by with specimens or equipment; or for any the Same Physician on the Same Day other reason when a normal, one-time, of the Procedure or Other Service reportable result is all that is required. This 27 Multiple Outpatient Hospital E/M modifier may not be used when other code(s) Encounters on the Same Date describe a series of test results (e.g., glucose 50 Bilateral Procedure tolerance tests, evocative/suppression 52 Reduced Services testing). This modifier may only be used 58 Staged or Related Procedure or for laboratory test(s) performed more than Service by the Same Physician once on the same day on the same patient. During the Postoperative Period 59 Distinct Procedural Service 99. Multiple Modifiers: Under certain 73 Discontinued Out-Patient Hospital/Ambulatory circumstances two or more modifiers Surgery Center (ASC) Procedure Prior may be necessary to completely delineate to the Administration of Anesthesia a service. In such situations modifier 99 74 Discontinued Out-Patient Hospital/ should be added to the basic procedure, and Ambulatory Surgery Center (ASC) Procedure other applicable modifiers may be listed After Administration of Anesthesia as part of the description of the service. 76 Repeat Procedure by Same Physician 77 Repeat Procedure by Another Physician Anesthesia Physical Status Modifiers 78 Return to the Operating Room for a Related Procedure During the Postoperative Period The Physical Status modifiers are consistent 79 Unrelated Procedure or Service by the Same with the American Society of Anesthesiologists Physician During the Postoperative Period ranking of patient physical status, and distinguish various levels of complexity of the anesthesia service provided. All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-03108) with the appropriate physical status modifier appended. Example: 00100-P1

Under certain circumstances, when another established modifier(s) is appropriate, it should be used in addition to the physical status modifier. 108 Level II (HCPCS/National) Modifiers codes to provide diagnostic granularity of service to enable provider to submit complete E1 Upper left, eyelid and precise genetic testing information without E2 Lower left, eyelid altering test descriptors. These modifiers are E3 Upper right, eyelid categorized by mutation. The first (numeric) digit E4 Lower right, eyelid indicates the disease category and the second F1 Left hand, second digit (alpha) digit denotes gene type. Introductory F2 Left hand, third digit guidelines in the molecular diagnostic and F3 Left hand, fourth digit molecular cytogenetic code sections of CPT F4 Left hand, fifth digit provide further guidance in interpretation F5 Right hand, thumb and application of genetic test modifiers. F6 Right hand, second digit F7 Right hand, third digit Neoplasia (solid tumor) F8 Right hand, fourth digit F9 Right hand, fifth digit 0A BRCA1 (Hereditary breast/ovarian cancer) FA Left hand, thumb 0B BRCA2 (Hereditary breast cancer) LC Left circumflex coronary artery 0C Neurofibromin (Neurofibromatosis, type 1) (Hospitals use with codes 92980- 0D Merlin (Neurofibromatosis, type 2) 92984, 92995, 92996) 0E c-RET (Multiple endocrine neoplasia, types LD Left anterior descending coronary 2A/B, familial medullary thyroid carcinoma artery (Hospitals use with codes 0F VHL (Von Hippel Lindau disease) 92980-92984, 92995, 92996) 0G SDHD (Hereditary paraganglioma) LT Left side (used to identify procedures 0H SDHB (Hereditary paraganglioma) performed on the left side of the body) 0I Her-2/neu QM Ambulance service provided under 0J MLH1 (HNPCC) arrangement by a provider of services 0K MSH2 (HNPCC) QN Ambulance service furnished directly 0L APC (Hereditary polyposis coli) by a provider of services 0M Rb (Retinoblastoma) RC Right coronary artery (Hospitals use with 1Z Solid tumor, not otherwise specified codes 92980-92984, 92995, 92996) RT Right side (used to identify procedures Neoplasia (lymphoid/hematopoetic) performed on the right side of the body) T1 Left foot, second digit 2A AML1 – also ETO (Acute myeloid leukemia) T2 Left foot, third digit 2B BCR – also ABL (Chronic myeloid, T3 Left foot, fourth digit acute lymphoid leukemia) T4 Left foot, fifth digit 2C CGF1 T5 Right foot, great toe 2D CBF beta (Leukemia) T6 Right foot, second digit 2E ML (Leukemia) T7 Right foot, third digit 2F PML/RAR alpha (Promyeleocytic leukemia) T8 Right foot, fourth digit 2G TEL (Leukemia) T9 Right foot, fifth digit 2H bcl-2 (Lymphoma) TA Left foot, great toe 2I bcl-1 (Lymphoma) 2J c-yc (Lymphoma) GENETIC TESTING CODE MODIFIERS 2K lgH (Lymphoma/leukemia) 2Z Lymphoid/hematopoietic neoplasia This listing of modifiers is intended for reporting not otherwise specified with molecular laboratory procedures related to genetic testing. Genetic test modifiers should be used in conjunction with CPT and HCPCS

109 Non-neoplastic hematology/coagulation Muscular, non-neoplastic

3A Factor V (Leiden, others) 6A Dystrophin (Duchenne/Becker (Hypercoagulable state) muscular dystrophy) 3B FACC (Fanconi anemia) 6B DMPK (Myotonic dystrophy, type 1) 3C FACD (Fanconi anemia 6C ZNF-9 (Myotonic dystrophy, type 2) 3D Beta globin (Thalassemia) 6D SMN (Autosomal recessive 3E Alpha globin (Thalassemia) spinal muscular atrophy) 3F MTHFR (Elevated homocysteine) 6Z Muscular, not otherwise specified 3G Prothrombin (Factor II, 20210A) Metabolic, other (Hypercoagulable state) 7A Apolipoprotein E (Cardiovascular disease, 3H Factor VIII (Hemophilia A/VWF) Alzheimer’s disease) 3I Factor IX (Hemophilia B) 7B Sphingomyelin phosphodiesterase 3J Beta globin (Nieman-Pick disease) 3Z Non-neoplastic hematology/coagulation, 7C Acid Beta Glucosidase (Gaucher disease) not otherwise specified 7D HFE (Hemochromatosis) 7E Hexosaminidase A (Tay-Sachs disease) Histocompatibility/blood 7Z Metabolic, other, not otherwise specified typing 4A HLA-A Metabolic, transport 4B HLA-B 4C HLA-C 8A CFTR (Cystic fibrosis) 4D HLA-D 8Z Metabolic, transport, not otherwise 4E HLA-DR specified Metabolic-pharmacogenetics 4F HLA-DQ 9A TPT (thiopurine methyltransferase) 4G HLA-DP (patients on antimetabolite therapy) 4H Kell 9L Metabolic-pharmacogenetics, 4Z Histocompatibility/blood typing, not otherwise specified not otherwise specified

Neurologic, non-neoplastic Dysmorphology

5A Aspartoacylase A (Canavan disease) 9M FGFR1 (Pfeiffer and Kallmann syndrome) 5B FMR-1 (Fragile X, FRAZA, syndrome) 9N FGFR2 (Crouzon, Jackson-Weiss, Apert, 5C Frataxin (Freidreich’s ataxia) Saethre-Chotzen syndromes) 5D Huntington (Huntington’s disease) 9O FGFR3 (Achondroplasia, Hypochondroplasia, 5E GABRA (Prader Willi-Angelman syndrome) Thanatophoric dysplasia, types I and 5F Connexin-26 (GJB2) (Hereditary deafness) II, Crouzon syndrome with acanthosis 5G Connexin-32 nigricans, Muencke syndromes) (X-linkedCharcot-Marie-Toothdisease) 9P TWIST (Saethre-Chotzen syndrome) 9Q 5H SNRPN (Prader Willi-Angelman syndrome) Catch-22 (22q11 deletion syndromes) 9Z 5I Ataxin-1 (Spinocerebellar ataxia, type 1) Dysmorphology not otherwise specified 5J Ataxin-2 (Spinocerebellar ataxia, type 2) 5K Ataxin-3 (Spinocerebellar ataxia, type 3, Machado-Joseph disease) 5L CACNA1A (Spinocerebellar ataxia, type 6) 5M Ataxin-7 (Spinocerebellar ataxia, type 7) 5N PMP-22 (Charcot-Marie-Tooth disease, type 1A) 5O ECP2 (Rett syndrome) 5Z Neurologic, non-neoplastic, not otherwise specified 110 Listed below are place of service codes and recognized American Indian or Alaska descriptions. These codes should be used Native tribe or tribal organization under a on professional claims to specify the entity 638 agreement, which provides diagnostic, where service(s) were rendered. Check with therapeutic (surgical and non-surgical), and individual payers (e.g., Medicare, Medicaid, other rehabilitation services to tribal members who private insurance) for reimbursement policies do not require hospitalization. regarding these codes. If you would like to comment on a code(s) or description(s), please 08. Tribal 638 Provider-based Facility: A facility send your request to [email protected]. or location owned and operated by a federally recognized American Indian or Alaska 9.3 Place of Service Codes Native tribe or tribal organization under a 638 agreement, which provides diagnostic, 01. Pharmacy: A facility or location where therapeutic (surgical and non-surgical), and drugs and other medically related items rehabilitation services to tribal members and services are sold, dispensed, or admitted as inpatients or outpatients. otherwise provided directly to patients 11. Office: Location, other than a hospital, 02. Telehealth: The location where health skilled nursing facility (SNF), military services and health related services treatment facility, community health are provided or received, through center, State or local public health clinic, or a telecommunication system. intermediate care facility (ICF), where the health professional routinely provides health 03. School: A facility whose primary examinations, diagnosis, and treatment of purpose is education. illness or injury on an ambulatory basis.

04. Homeless Shelter: A facility or location 12. Home: Location, other than a hospital whose primary purpose is to provide or other facility, where the patient temporary housing to homeless receives care in a private residence. individuals (e.g., emergency shelters, individual or family shelters). 13. Assisted Living Facility: Congregate residential facility with self-contained living 05. Indian Health Service Free-standing units providing assessment of each resident’s Facility: A facility or location, owned and needs and on-site support 24 hours a day, 7 operated by the Indian Health Service, which days a week, with the capacity to deliver or provides diagnostic, therapeutic (surgical arrange for services including some health and non-surgical), and rehabilitation care and other services. (effective 10/1/03) services to American Indians and Alaska Natives who do not require hospitalization. 14. Group Home: A residence, with shared living areas, where clients receive 06. Indian Health Service Provider-based supervision and other services such Facility: A facility or location, owned and as social and/or behavioral services, operated by the Indian Health Service, which custodial service, and minimal services provides diagnostic, therapeutic (surgical (e.g., medication administration). and non-surgical), and rehabilitation services rendered by, or under the supervision of, 15. Mobile Unit: A facility/unit that moves physicians to American Indians and Alaska from place-to-place equipped to provide Natives admitted as inpatients or outpatients. preventive, screening, diagnostic, and/or treatment services. 07. Tribal 638 Free-standing Facility: A facility or location owned and operated by a federally

111 20. Urgent Care Facility: Location, distinct from of injured, disabled, or sick persons, or, a hospital emergency room, an office, or a on a regular basis, health-related care clinic, whose purpose is to diagnose and treat services above the level of custodial care to illness or injury for unscheduled, ambulatory other than mentally retarded individuals. patients seeking immediate medical attention. 33. Custodial Care Facility: A facility 21. Inpatient Hospital: A facility, other than which provides room, board and other psychiatric, which primarily provides personal assistance services, generally diagnostic, therapeutic (both surgical and on a long-term basis, and which does nonsurgical), and rehabilitation services by, or not include a medical component. under, the supervision of physicians to patients admitted for a variety of medical conditions. 34. Hospice: A facility, other than a patient’s home, in which palliative and 22. Outpatient Hospital: A portion of a hospital supportive care for terminally ill patients which provides diagnostic, therapeutic (both and their families are provided. surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not 41. Ambulance – Land: A land vehicle specifically require hospitalization or institutionalization. designed, equipped and staffed for lifesaving and transporting the sick or injured. 23. Emergency Room – Hospital: A portion of 42. Ambulance – Air or Water: An air or a hospital where emergency diagnosis and water vehicle specifically designed, treatment of illness or injury is provided. equipped and staffed for lifesaving and transporting the sick or injured. 24. Ambulatory Surgical Center: A freestanding facility, other than a physician’s office, 49. Independent Clinic: A location, not part of where surgical and diagnostic services a hospital and not described by any other are provided on an ambulatory basis. Place of Service code, that is organized and 25. Birthing Center: A facility, other than a operated to provide preventive, diagnostic, hospital’s maternity facilities or a physician’s therapeutic, rehabilitative, or palliative office, which provides a setting for labor, services to outpatients only. (Effective 10/1/03) delivery, and immediate post-partum care as well as immediate care of new born infants. 49. Federally Qualified Health Center: A facility located in a medically underserved 26. Military Treatment Facility: A medical area that provides Medicare beneficiaries facility operated by one or more of the preventive primary medical care under Uniformed Services. Military Treatment the general direction of a physician. Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) 50. Inpatient Psychiatric Facility: A facility facilities now designated as Uniformed that provides inpatient psychiatric Service Treatment Facilities (USTF). services for the diagnosis and treatment of mental illness on a 24-hour basis, by 31. Skilled Nursing Facility: A facility which or under the supervision of a physician. primarily provides inpatient skilled nursing care and related services to patients who 51. Psychiatric Facility-Partial Hospitalization: require medical, nursing, or rehabilitative A facility for the diagnosis and treatment services but does not provide the level of of mental illness that provides a planned care or treatment available in a hospital. therapeutic program for patients who do not require full time hospitalization, but 32. Nursing Facility: A facility which primarily who need broader programs than are provides to residents skilled nursing care possible from outpatient visits to a hospital- and related services for the rehabilitation based or hospital-affiliated facility. 112 52. Community Mental Health Center: A facility 60. Mass Immunization Center: A location that provides the following services: outpatient where providers administer pneumococcal services, including specialized outpatient pneumonia and influenza virus vaccinations services for children, the elderly, individuals and submit these services as electronic who are chronically ill, and residents of the media claims, paper claims, or using the CMHC’s mental health services area who have roster billing method. This generally takes been discharged from inpatient treatment place in a mass immunization setting, such at a mental health facility; 24 hour a day as, a public health center, pharmacy, or mall emergency care services; day treatment, but my include a physician office setting. other partial hospitalization services, or psychosocial rehabilitation services; screening 61. Comprehensive Inpatient Rehabilitation for patients being considered for admission Facility: A facility that provides to State mental health facilities to determine comprehensive rehabilitation services under the appropriateness of such admission; the supervision of a physician to inpatients and consultation and education services. with physical disabilities. Services include physical therapy, occupational therapy, speech 54. Intermediate Care Facility/Mentally pathology, social or psychological services, Retarded: A facility which primarily and orthotics and prosthetics services. provides health-related care and services above the level of custodial care to 62. Comprehensive Outpatient Rehabilitation mentally retarded individuals but does Facility: A facility that provides not provide the level of care or treatment comprehensive rehabilitation services available in a hospital or SNF. under the supervision of a physician to outpatients with physical disabilities. Services 55. Residential Substance Abuse Treatment include physical therapy, occupational Facility: A facility which provides treatment for therapy, and speech pathology services. substance (alcohol and drug) abuse to live-in residents who do not require acute medical 65. End-Stage Renal Disease Treatment care. Services include individual and group Facility: A facility other than a hospital, which therapy and counseling, family counseling, provides dialysis treatment, maintenance, laboratory tests, drugs and supplies, and/or training to patients or caregivers psychological testing, and room and board. on an ambulatory or home-care basis.

56. Psychiatric Residential Treatment Center: 71. Public Health Clinic: A facility maintained A facility or distinct part of a facility for by either State or local health departments psychiatric care which provides a total 24-hour that provide ambulatory primary medical therapeutically planned and professionally care under the general direction of staffed group living and learning environment. a physician. (effective 10/1/03)

57. Non-residential Substance Abuse 72. Rural Health Clinic: A certified facility Treatment Facility: A location which which is located in a rural medically provides treatment for substance (alcohol underserved area that provides and drug) abuse on an ambulatory basis. ambulatory primary medical care under Services include individual and group the general direction of a physician. therapy and counseling, family counseling, laboratory tests, drugs and supplies, and 81. Independent Laboratory: A laboratory psychological testing. (effective 10/1/03). certified to perform diagnostic and/ or clinical tests independent of an institution or a physician’s office.

99. Other Place of Service: Other place of service not identified above. 113 Notes

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114 ______

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115 SVHP-2091 Rev. 12/17