Provider Manual 2021 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 Privacy Regulation & Medical Records .................................................................................. 11 3.4 Sanford Health Plan Comercial Products .............................................................................. 12 3.4.1 Accessing Provider Directory .................................................................................... 13 3.4.2 How to Request Prior Authorization .......................................................................... 13 3.5 Sanford Health Plan Provider Networks ................................................................................ 14 3.5.1 Sanford SAFEGUARD (Short-term Limited Duration) ................................................... 14 3.5.2 Simplicity Plans .............................................................................................................. 15 3.5.3 Sanford TRUE Plans ....................................................................................................... 16 3.5.4 Sanford PLUS Plans ....................................................................................................... 17 3.5.5 Signature Series & Legacy Plans .................................................................................. 18 3.5.6 Elite1 Plans ..................................................................................................................... 19 3.6 Third Party Administrator (TPA) Services: ............................................................................. 20 3.7 Medicare Plans ........................................................................................................................ 22 3.7.1 Medicare SELECT Supplement Plans ............................................................................. 22 3.7.2 Medicare Supplement Plans .......................................................................................... 24 3.8 Government Products: .................................................................................................................. 25 3.8.1 North Dakota Medicaid Expansion ............................................................................ 25 3.8.2 North Dakota Public Retirement System Medicare Supplement ............................. 31 3.8.3 North Dakota Public Employee Retirement System Non-Medicare ........................ 32 Section 4: Provider Relations .................................................................................................................34 3 4.1 Provider Relations Department ..............................................................................................34 4.2 Contracting Department .........................................................................................................34 4.3 Credentialing & Re-credentialing ...........................................................................................34 4.3.1 Locum Tenans providers ............................................................................................ 35 4.3.2 Supervising Physician ................................................................................................ 35 4.4 Credentialed Providers ........................................................................................................... 35 4.5 Practitioners Who Do Not need to be Credentialed/Re-credentialed ................................... 36 4.5.1 Inpatient Setting ......................................................................................................... 36 4.5.2 Freestanding Facilities ............................................................................................... 36 4.5.3 Practitioners who are not accepted by Sanford Health Plan .................................... 36 4.6 Ongoing Monitoring Policy ...................................................................................................... 36 4.7 Provider Rights & Responsibilities ......................................................................................... 37 4.7.1 Right to Review & Correct Credentialing Information .............................................. 37 4.7.2 Refusing to Treat a Sanford Health Plan Member ....................................................38 4.7.3 Member Eligibility Verification ...................................................................................38 4.7.4 Medical Record Standards .........................................................................................38 4.7.5 Practitioner Office Site Quality .................................................................................. 39 4.7.6 Cultural and Linguistic Competency ......................................................................... 39 4.8 Primary Care Responsibilities ................................................................................................40 4.9 Access Standards .................................................................................................................... 41 4.9.1 Primary Care Physician ............................................................................................. 41 4.9.2 Emergency Services .................................................................................................. 41 4.9.3 Urgent Care Situation ................................................................................................ 41 4.9.4 Ambulance Service .................................................................................................... 41 4.9.5 Out of Area Services .................................................................................................. 42 4.9.6 Treatment of Family Members ................................................................................... 42 4.9.7 Provider Terminations................................................................................................ 42 4.9.8 Notification of Provider Network Changes ................................................................ 42 Section 5: Quality Improvement & Medical Management .......................................................................44 5.1 Quality Improvement Program ...............................................................................................44 5.1.1 Complex Case Management Referral Guide .............................................................45 4 5.2 Medical Management Program ..............................................................................................45 5.2.1 Utilization Review Process .........................................................................................45 5.2.2 New Medical Service or Product Consideration .......................................................46 5.2.3 Prior Authorizations ...................................................................................................46 5.2.4 Sanford Health Plan Referral Center ........................................................................ 49 5.2.5 Coordinated Services Program (CSP) ....................................................................... 49 5.2.6 Pharmacy Management and Formulary Program Information ................................ 50 5.2.7 Sanford Health Plan Formulary ................................................................................50 Section 6: Filing Claims .......................................................................................................................... 51 6.1 Member Eligibility & Benefit Verification ............................................................................... 51 6.1.1 North Dakota Medicaid Expansion Eligibility Adjustment ....................................... 51 6.2 Claims Submission .................................................................................................................. 51 6.2.1 Paper Claims Submission .......................................................................................... 52 6.2.2 Corrected/Voided Claims Submission ...................................................................... 52 6.3 Provider EDI Resources ..........................................................................................................53