provider fast facts - sanford health...simplicity – individual, small and large group plans...

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Provider Fast Facts April 29, 2019 | A monthly eNewsletter from Sanford Health Plan Updated Provider Manual Available Sanford Health Plan’s provider manual has been updated and is available to you online at sanfordhealthplan.com/providers/forms. If your office is in need of a printed copy, please contact Provider Relations. Policies referenced in the manual can be found inside the portal and are located under the ‘Resources’ tab. Coming July 2019: Optum Claims Editing System Implementation Sanford Health Plan is in the process of updating its claims editing software to Optum Claims Editing System (CES). The update is expected to be implemented this July. As with our current claims editing system, Experian, Optum CES utilizes national coding edits, edits based on CPT guidelines, specialty society edits and clinically derived edits. Watch for additional information about this in future editions of Fast Facts. 1

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Page 1: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

Provider Fast FactsApril 29, 2019 | A monthly eNewsletter from Sanford Health Plan

Updated Provider Manual AvailableSanford Health Plan’s provider manual has been updated and is available to you online at sanfordhealthplan.com/providers/forms. If your office is in need of a printed copy, please contact Provider Relations. Policies referenced in the manual can be found inside the portal and are located under the ‘Resources’ tab.

Coming July 2019: Optum Claims Editing System Implementation Sanford Health Plan is in the process of updating its claims editing software to Optum Claims Editing

System (CES). The update is expected to be implemented this July.

As with our current claims editing system, Experian, Optum CES utilizes national coding edits, edits

based on CPT guidelines, specialty society edits and clinically derived edits.

Watch for additional information about this in future editions of Fast Facts.

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Page 2: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

Need an easy resource for Sanford Health Plan ID cards? There is an updated document available to providers on our website at sanfordhealthplan.com/providers/forms that compiles the different ID cards that Sanford Health Plan distributes to our members. This document includes the various cards distributed for our Flexible Spending program as well. To download a ID Card Reference Sheet CLICK HERE

Sanford Health Plan ID Cards

Sanford Health Plan ID cardsSubmit claims to: Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109

• Medicare plans bill Medicare first.• For providers outside the Sanford Health Plan service area, if there is an address along with a network logo,

submit claims to that address.Electronic payor ID #: 91184Online resource: sanfordhealthplan.com

For questions, call: Sanford Health Plan NDPERS ND Medicaid Expansion- Customer Service – Benefits eligibility claims status and inquiries (800) 752-5863 (800) 499-3416 (855) 305-5060- Utilization Management – Prior authorizations (800) 805-7938 (888) 315-0885 (855) 276-7214- Pharmacy Department – Prescription coverage or drug authorizations (855) 305-5062 (877) 658-9194 (855) 263-3547

Fully-insured commercial products

Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network) (Focused Network)

Sanford PLUS – large group plans elite1 – individual plans (Tiered Network) (Broad Network)

Signature Series & Legacy – Medicare Select plans small and large group plans Medicare Supplement plans (Broad Network)

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

5/31 RP#:27 JobID#:635664LGP/XYZ00123456/

JOHN A LGP

ID: Z9999990101

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

JANE B LGP

ID: Z9999990102

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

DO NOTUSE

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

7/31 RP#:25 JobID#:635664COM/XYZ00123456/

JOHN A COM

ID: Z9999990101

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

JANE B COM

ID: Z9999990102

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

DO NOTUSE

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

25/31 RP#:7 JobID#:635664IOT/XYZ00123456/

JOHN A IOT

ID: Z9999990101

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

JANE B IOT

ID: Z9999990102

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

DO NOTUSE

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

26/31 RP#:6 JobID#:635664IND/XYZ00123456/

JOHN A IND

ID: Z9999990101

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

JANE B IND

ID: Z9999990102

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

DO NOTUSE

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

2/3 RP#:2 JobID#:635665MSP/XYZ00123456/

ID: Z9999990101

Name JOHN A MSP

Grp: XYZ00123456

Care Type: Medicare Supplement

Svc Type: Medical

Effective: MemberEff

02-01-2017

Medical

JOHN A MSP

ID: Z9999990101

XYZ00123456Grp:

MemberEffEffective:

Name

Care Type:

Svc Type:

02-01-2017

DO NOTUSE

Welcome to Sanford Health Plan! Your health insurance identification card(s) for medical and prescription benefits are enclosed. Each covered member will receive their own ID card which should be shown at each provider visit or when filling a prescription. An explanation of the important information shown on your ID card is below for your reference.

We encourage you to sign up for our secure member portal at sanfordhealthplan.com/memberlogin for 24/7 access to all your benefits information.

Our team is ready to help if you have any questions about your benefits or new ID card. You can reach Customer Service toll free Monday through Friday from 8 a.m. to 5 p.m. CT at (800) 752-5863 | TTY/TDD: (877) 652-1844. For help in a language other than English, call toll free (800) 892-0675.

[ Peel off cards carefully from front side. ]

28/31 RP#:4 JobID#:635664IOX/XYZ00123456/

JOHN A IOX

ID: Z9999990101

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

JANE B IOX

ID: Z9999990102

XYZ00123456

In Network Office Visit:

Grp:

OV Copay Text

02-01-2017

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

Members: For urgent or emergency care when you are out of the local service area, seek treatment at the nearest medical facility or call 911. Notify Sanford Health plan of an admission as soon as it is reasonably possible and no later than 48 hours after physically or mentally able to do so.

Eligibility: This card is for identification purposes only. It does not constitute proof of eligibility.

DO NOTUSE

MEMBER NAME

MEMBER NAME

MEMBER NAME

MEMBER NAME

MEMBER NAME

MEMBER NAME

2

Page 3: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

Most Commonly Questioned Denial Codes We receive a variety of questions from Provider offices inquiring whether denied charges are the responsibility of the Provider as a write off, or billable to the Member/Patient. Outlined below are the most commonly questioned remit codes detailing how each of these codes affects your reimbursement.

EOP REMIT CODE DESCRIPTION OF DENIAL RESPONSIBILITY

EXG4 PR-1000000 Incomplete or insufficient injury investigation Member/Patient

Member needs to call Optum (800) 529-0577.

PNC PR-20096 Services billed are either an exclusion, require a referral, or the member has already exceeded their plan limit. Member/Patient

No further action required to SHP unless you feel it has processed in error; you would then submit a claim reconsideration.

DCD CO-18 Claim denied as a duplicate service. Provider

No further action required to SHP unless you feel it has processed in error; you would then submit a claim reconsideration.

29MC CO-29 Deny Timely Filing – Provider Write Off Provider

No further action required to SHP unless you feel it has processed in error; you would then submit a claim reconsideration.

W9DNY CO-102 W9 Needed Provider

Fax copy of current W9 to (605) 328-7224.

CLMCT CO-102 Claim not submitted according to contract Provider

Review your contract to the submitted claim(s); submit corrected claim.

N197 PR-80227 Denied for COB information not returned. Member/Patient

Member needs to contact Sanford Health Plan Customer Service.

MISCD CO-96 More Specific coding required. Member not responsible. Provider

Review coding and submit a corrected claim.

PRNFFS CO-2007 Provider Not Enrolled in ND State Medicaid Program Provider

To become a participating provider for ND Medicaid Expansion, see Provider Enrollment Guidance online at sanfordhealthplan.org/providers/medicaid-expansion

NCVG PR-27 Member not eligible for coverage. Member/Patient

Patient does not have eligible coverage for the submitted date(s) of service. Contact the patient for updated insurance information.

Seeing different denials and have questions? Contact Provider Relations for more details. Thank you for the great care you give to our members!

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Page 4: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

North Dakota Medicaid Expansion Eligibility Adjustments Sanford Health Plan processes eligibility files received from North Dakota Department of Human Services (NDDHS) for benefits and claims adjudication. Please note: Sanford Health Plan may be notified by NDDHS that a member has lost eligibility retroactively. When there is a change in eligibility, Sanford Health Plan will process any overpayments by taking deductions on future claims. Claim adjustments will appear on the next EOP for any effected claims. For more information on how providers are able to verify a member’s eligibility, please refer to section 6.1.1 of Sanford Health Plan’s Provider Manual.

Billing Reminder : National Provider Identifier (NPI) numbersAn NPI is a unique, ten digit identifier assigned to a provider or facility. Sanford Health Plan has seen an increase in claim denials due to NPI’s being submitted incorrectly.

On the CMS-1500 claim form or the electronic equivalent, report the NPIs in:

Field 24J Type 1 NPI (Rendering Provider)Field 32A Type 2 NPI (Service Facility) Field 33A Type 1 or 2 NPI (Billing Provider)

On the UB-04 claims form, the NPIs in:

Field 56 NPI (Billing Facility/Provider)Field 76-79 Type 1 NPI

Providers can reference the Sanford Health Plan Provider Manual for more information, or call Provider Relations at (800) 601-5086 if you have questions.

Updated Prescription Drug Prior Authorization Request/Formulary Exception Form: is available online at sanfordhealthplan.com/providers/pharmacy-information

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Page 5: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

Policy Updates:

Benefit Reimbursement Policy Updates: To view this benefit reimbursement policy, log in to the provider portal mySanfordHealthPlan; benefits and reimbursement policies are located under the ‘Resources’ tab.

• Home Infusion• Lab, X-ray Rider• Lab, X-ray, Minor Procedure• Metabolic and Bariatric Surgery

• Nutritional Counseling and Medical Nutrition Therapy (MNT)

• Obstetric (Pre/Post Natal) • Vision Therapy

Pharmacy Policy Updates: The following new and updated policies are effective March 7, 2019.New Policies:

• Ajovy • Epidiolex • Galafold • Ilumya • Mulpleta

• Orilissa • Palynziq • Qbrexza Step therapy • Takhzyro

Updated Policies:• Adcirca • Adempas • Aimovig • Aldurazyme • Antidepressant (SNRI/SSRI) Step Therapy • Atypical Antipsychotic Step Therapy • Benlysta IV • Benlysta SC • Berinert • Brand with Generic Available • Cinryze • Elaprase • Emflaza • Epoprostenol (Flolan, Veletri) • Esbriet • Fibromyalgia-Neuropathy Step Therapy • Formulary Exclusion • Forteo • GLP-1 Receptor Agonist Step Therapy • Immune Globulin (IVIG, SCIG)• Letaris • Lonhala Step therapy • Morphine Equivalent Dose (MED)

greater than 180 • Naglazyme

• New to Market Medication • Nuplazid Contingent Therapy • Ofev • Opsumit • Orenitram • ORM Long-Acting Opioids • ORM Short-Acting Opioids • Overactive Bladder (OAB) Step therapy • Pharmaceutical Samples and Formulary

Management • Praluent • Prolia • Prostaglandin (Ophthalmic) Step therapy • Quantity Level Limits • Remodulin • Repatha • Sildenafil (Revatio) IV • Sildenafil (Revatio) Oral • Spinraza • Tetrabenazine (Xenazine) • Tracleer • Tymlos • Tyvaso • Uceris Step therapy • Uloric

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Page 6: Provider Fast Facts - Sanford Health...Simplicity – individual, small and large group plans Sanford TRUE – individual, small and large group plans (Broad Network)Our team is ready

Hearing or speech impaired TTY | TDD (877) 652-1844

Translation Assistance for Non-English Speaking Members (800) 892-0675

Contact Us:CONTACT FOR: Eligibility & benefits, claim status, provider directory, complaints, appeals, report member discrepancy information

[email protected] ServiceMonday-Friday, 7:30 a.m. to 5:00 p.m. CST | 800) 752-5863

NDPERS Customer ServiceMonday-Friday, 8:00 a.m. to 5:30 p.m. CST | (800) 499-3416

ND Medicaid ExpansionMonday-Friday, 7:30 a.m. to 5:00 p.m. CST | (855) 305-5060

CONTACT FOR: Preauthorization/precertification of prescriptions or formulary questions

[email protected] (855) 305-5062

NDPERS Pharmacy (877) 658-9194

ND Medicaid Expansion (855) 263-3547

CONTACT FOR: Preauthorization/precertification for medical [email protected] Management (800) 805-7938

NDPERS Utilization Management (888) 315-0885

ND Medicaid Expansion (855) 276-7214

CONTACT FOR: Assistance with provider portal password resets & logging in fee schedule inquiries, check adjustments & reconciling a negative balance, request explanation of payment (EOP), claim reconsideration requests, W9 form, change/updating information, provider education

[email protected]

Provider Relations (800) 601-5086

CONTACT FOR: Requests to join the network and contracted related questions, fee schedule negotiation, provider credentialing

[email protected]

Provider Contracting (855) 263-3544

SVHP-2860 Rev. 4/19

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