As you are aware, we are facing a potential pandemic of the H1N1 influenza. You will undoubtedly receive many phone calls requesting prophylactic prescriptions for antiviral medication. In the interest of appropriateness of therapy and ensuring adequate supplies for high risk patients, Sanford Health Plan is initiating a quantity limit on Tamiflu and Relenza. Effective April 8, 2009, our members will be limited to one FDA approved treatment course of Tamiflu or Relenza in a six month period. This should be sufficient to provide prophylaxis for exposure or treatment for active disease. You have received guidelines from the CDC for prophylaxis and treatment. I urge you to follow these guidelines and reserve antivirals for those patients who meet CDC criteria.
Thank you for your cooperation in this difficult time.
Respectfully,
Dr. Michael Crandell, Chief Medical Officer
Pharmacy Updates Effective May 1, 2009
2009 Preventive Health Guidelines and Childhood/Adolescent Immunization Schedules Updated
The changes listed below have been made to the 2009 preventive health guidelines.
- Changed the title from “Preventive Health Guidelines” to “Preventive Health Guidelines and Other Covered Services”
- “Preventive Health Guidelines” for Youth
a. Number of Well Care Visits to read:
i. 0 – 13 months 6 visits
ii. 14 – 23 months 2 visits
iii. Visits for ages 2 - 6 years remain as listed
b. Hemoglobin or Hematocrit:
Coverage to read, “One Hemoglobin OR One Hematocrit between ages 9-15 months
Changes were only made to the “Preventive Health Guidelines” for Youth
Provider Preventive Health Guidelines
Diabetic Eye Exam Copays
As you are aware, retinopathy is one of the most devastating complications of Diabetes. Our data, based on claims and HEDIS® scores (health plan performance measure data), indicates that only 53.77% of our diabetic members were screened for diabetic retinopathy last year.
To encourage our diabetic members to receive proper eye care, Sanford Health Plan is waiving the copay for its diabetic members for their annual diabetic retinal or dilated eye exam. We hope that this will help persuade some members to see you who might otherwise find it financially difficult.
In order for the member’s eye exam claim and copay to be reimbursed properly, the claim needs to be submitted with one of the CPT codes below in conjunction with one of the diagnosis codes below. This will be allowed only for the member's annual diabetic eye exam - one exam per member per year.
CPT Codes: 92002, 92004, 92012, 92014, 92018, 92019, 92225, 99203-99205, 99213-99215, 99242-99245
Primary Diagnosis Codes: 250.00 through 250.9
Medicare 2009 Deductibles
Medicare Part A Deductible is $1068.00. Medicare Part B Deductible is $135.00.
What Do I Need to Know About Mumps
pdf (144k)
2008 Formulary Changes
pdf (27k)
Refusing to Treat a Sanford Health Plan Member
It is your right as a provider to refuse to continue to provide services to a Sanford Health Plan member. While this is most likely a very rare event, it is required that you contact Sanford Health Plan in such an event so we can assist this member in transitioning to a similar specialist. If you find yourself in a situation where you choose to discontinue rendering services to a Sanford Health Plan patient, please contact your Provider Relations representative or contact the Provider Relations department toll free at 1-800-601-5086.
Digital Health Plan
Have you ever misplaced an Explanation of Payment (EOP) and needed a copy? Digital Health Plan will allow providers to verify member eligibility, member benefits, claim status and access EOP's. Note: an EOP will only be available for claims that have been completely processed.
As a provider, you must have a personal account to Digital Health Plan in order to view an EOP. Please log on to Digital Health Plan.
Feel free to contact the Provider Relations Department at 800-601-5086 with questions.
Credentialing
Sanford Health Plan is committed to be in full compliance with the standards set forth by National Committee for Quality Assurance (NCQA). NCQA requires that all contracted providers be completely credentialed before rendering services to Health Plan members. To meet this requirement, all providers must be fully Credentialed and approved by Sanford Health Plan‘s Credentialing Committee prior to becoming effective in our network as a participating provider. This includes any new providers joining the practice or group. The Provider’s effective date with Sanford Health Plan will no longer be the date contracts were signed or the date Sanford Health Plan was notified to add the provider to existing contracts; the effective date will be the date credentialing was completed. Once the Credentialing process has been completed, Providers will receive a letter notifying them of their effective date and Sanford Health Plan provider identification number for claims submission. The intent of Credentialing is to conduct timely verification of information to ensure that practitioners have the legal authority and relevant training and experience to provide quality of care.
How long does the Credentialing process generally take to complete? The Credentialing process should take as little as 30 days but no more than 180 days depending on the ability of the Sanford Central Verification Office to verify the Provider’s credentialing information.
What happens if a provider provides services to a Sanford Health Plan member prior to completing the Credentialing process? In the event Sanford Health Plan receives claims from a provider prior to completing Credentialing at the time services were rendered, the charges will be denied and it is the provider's responsibility to write off applicable charges. This is why it is important to send in completed Credentialing applications as soon as it is known a Provider will be starting or joining a practice.
Where can I get a Credentialing application?
Credentialing applications can be found on the Provider website under Credentialing Information.
Thank you in advance for your cooperation with Sanford Health Plan’s Credentialing Policy. If you have any questions, please contact the Provider Relations Department at 1-800-601-5086.
Provider Newsletters
Medical Updates Newsletters are sent to participating providers when the Medical Director of Sanford Health Plan wants to relay important information directly to providers. The Provider Perspective goes to participating providers three times a year and contain important provider reminders and information pertinent to being a Sanford Health Plan provider.
Medical Updates Newsletters
November 2008 Medical Updates
October 2008 Medical Updates
September 2008 Medical Updates
Provider Perspective
Fall 2009
Summer 2009
Winter 2009 | 
