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 ..........................................................................................................