Common Questions

Below, you'll find answers to some of the most common insurance questions. If you need additional assistance, please refer to your plan documents or contact Customer Service.

Claims

How are my claims paid?

After you receive medical care, most providers will file a claim for reimbursement, but you will need to file a claim if your provider did not file one for you. This may occur if you do not show your ID card when receiving care. Complete a Claim Form or contact Customer Service to receive a form by mail. A copy of your itemized statement (breakdown of charges) from your provider and proof of payment will be needed to process the claim.

After your claim is received and processed according to your benefits, Sanford Health Plan will send payment to the provider and you will receive an Explanation of Benefits (EOB) explaining how your benefits were processed. Most claims are processed within 30 days, but may take longer if additional information is needed. In these cases, we will contact you and your provider if needed.

What if I need to file a manual claim?

If your provider did not file a claim for you, complete a Claim Form and return to Sanford Health Plan as soon as possible. In addition to the form, we'll also need an itemized receipt of the charges. Your name and ID number, the provider's name, when you received the service, your diagnosis, the type of service you received and the charge for the service must be shown on the statement. Also include a copy of your explanation of benefits and your receipt showing what you've paid. The following types of receipts are accepted: credit card receipt or statement, image of a processed check or a signed cash receipt that shows the provider's business information.

When do claims need to be submitted?

  • For in-network (participating) providers, all claims must be received within 180 days from the date of service.
  • For out-of-network (non-participating) providers, claims must be received within 180 days from the date of service.
  • If you use a national network provider, claims must be submitted within 365 days.
  • If your claim is not received in the allotted time, you will be responsible for all costs.

What if I disagree with how a claim was paid?

You have the right to appeal. Check your policy for more information, contact Customer Service or complete an Appeal Form to start the appeal process.

Who is Optum?

Optum is a company who helps us handle claims that could be someone else's responsibility, and may become involved if you have broken bones, head, neck or back injuries, burns, trauma or joint injuries. If you receive a call or form in the mail from Optum, please respond within 10 days or your claims may be denied. You can reach Optum by phone at (800) 529-0577 or complete the form online at icc.optum.com. All information provided is confidential and will only be used for insurance purposes.

What if I'm in an accident or have a work-related injury?

If you need medical care and another person or company is responsible, please contact us. We have partnered with Optum, a company who helps us handle claims that could be someone else's responsibility. If you receive a call or form in the mail from Optum, please respond within 10 days or your claims may be denied. You can reach Optum by phone (800) 529-0577 or complete the form online at icc.optum.com. All information provided is confidential and will only be used for insurance purposes.


Common Insurance Terms

Allowed Amount

Shown on the explanation of benefits (EOB), this is the maximum amount we will pay a provider for a covered service. Even with the same service, the allowed amount may be different for in-network versus national network providers.

Ancillary Service

Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care. Ancillary fees may also be associated with obtaining prescription drugs that are not on the Formulary (covered medication list).

Claim

The bill sent to us from your provider showing the services provided to you.

Co-insurance

The percentage of costs for covered services you are responsible for after you meet your deductible. Co-insurance is based on the allowed amount for the service. If you've met your deductible and your coinsurance is 80/20, the plan then pays for 80 percent of the allowed amount for a service and you pay 20 percent. For example, if you've met your deductible and the allowed amount for a service is $100, the plan would pay $80 and you would be responsible for $20.

Copay or copayment

The dollar amount you pay each time you visit the doctor or fill a prescription. For example, if your copay is $20, you would pay this amount for an office visit, and we cover the rest of the allowed amount. Copays do not apply to your deductible.

Covered Services

Healthcare services that Member is entitled to under their policy.

Deductible

The cost of covered services you pay at 100 percent before Sanford Health Plan begins to pay. For example, if your deductible is $1,500, the plan won't pay until you've paid $1,500 out of pocket for services that are subject to the deductible, such as labs, imaging, procedures and hospitalizations.

Excluded (non-covered) services

Services that Sanford Health Plan does not pay for or cover. Non-covered services do not apply to your deductible and/or coinsurance. Please review your plan document for more information.

Formulary

A list of medications covered by the plan, which may be updated throughout the year.

Medically necessary

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms that meet accepted standards of medicine.

Network

The facilities, providers and suppliers Sanford Health Plan has contracted with to provide health care services.

Non-preferred (out of network) provider

A health care provider not contracted with Sanford Health Plan. There is no discount for services, so you will pay more (or the entire cost) for medical services.

Out-of-pocket maximum (limit)

The maximum amount you'll pay in a calendar year for covered medical expenses before your insurance plan begins to pay at 100 percent. Depending on the type of plan you have, copays may or may not apply toward your out of pocket maximum or be required after you meet it.

Prior Authorization (pre-approval or certification)

A request submitted for approval of certain services including procedures, hospitalizations and medications before they are received (except in an emergency). We will review the request to determine if it is medically necessary and mail you the determination. Prior authorization does not guarantee the plan will cover the cost.

In-network or preferred provider

A provider contracted with Sanford Health Plan that allows you to receive health services at a discounted rate. You can save money by using these providers.

Premium

The amount you pay Sanford Health Plan on a monthly basis for your health insurance coverage. This amount does not apply toward your deductible and/or coinsurance.

Utilization review

A process which compares requests for medical services (utilization) to recommended treatment guidelines. The process also confirms requested services are appropriate treatment and medically necessary.


Insurance 101

What services usually apply to the deductible?

Typically, only office visits and prescriptions require a copay. Charges for other services, such as labs, imaging, procedures and hospitalizations will need to be paid by you until you meet your deductible amount. See your Summary of Benefits and Coverage to determine what services will apply to your deductible. If you see a preferred provider, a discount will be applied to the amount billed. The allowed amount (amount billed minus the discount) is the maximum amount Sanford Health Plan will pay for a service, and this is the amount that is applied to your deductible.

How do deductible and coinsurance work?

If you have a $1,000 deductible, 20% coinsurance and $2000 out of pocket maximum, and have a $1500 covered service, benefits would be applied as follows:

The Member pays $1000 out of pocket to meet the deductible. 20% coinsurance now applies. A $500 balance remains, which is applied to coinsurance. The Plan pays 80% of the $500 ($400) and the Member pays 20% ($100). The Member has now paid $1100 out of pocket. After another $900 is paid, the Member will reach the out of pocket maximum (limit) and the Plan will then pay 100% of charges.

(Depending on your plan, copays may or may not apply toward the out of pocket maximum or be required after you meet the out of pocket maximum.)

What if I want to know more about my provider?

Please contact Customer Service; we are happy to provide information about your provider's qualifications.

What if I need to see a specialist or need behavioral health services?

Work with your primary care provider for a referral, or arrange an appointment on your own. If you have trouble obtaining an appointment with a behavioral health provider, call the 24-hour behavioral health assessment line at (800) 691-4336. Remember, if you choose to see an out of network provider, you must receive prior authorization from Sanford Health Plan. This includes services from Mayo Clinic, Rochester, St. Mary's or University of Minnesota. If approved and the services you receive are eligible, claims will be processed at the in-network benefit level.

What if I need emergency care?

In an emergency, call 911 or go to the nearest emergency room, in or out of network. The plan will cover services (per your benefit plan) needed to screen and stabilize members who are experiencing a medical emergency and no preapproval is necessary.

What if I am traveling outside of the United States?

Covered services for medically necessary emergent and urgent care services received in a foreign country are covered at the in-network level. There is no coverage for elective health care/treatment outside the United States. Please note: You may be required to pay for services up front if receiving care outside the U.S. If this occurs, ask the provider for a detailed statement and submit a manual claim for reimbursement.

What if I have other insurance?

If you have insurance through another carrier, please complete a Coordination of Benefits Form to determine which insurance pays first and which pays second. We'll work with the other company to make sure we are working together to process your claims. This will lead to more accurate claims processing and you'll save money by maximizing your benefit plans.


Flexible Spending (FSA), Health Reimbursement (HRA) and Health Savings (HSA) Accounts

How do I file a claim for reimbursement?

In your Flexible Spending, Health Savings or Health Reimbursement Account Portal, select "I want to file a claim" on the home page. Follow the prompts and enter requested information. Upload your receipt and click "Add claim". If you have more than one claim, click "Add another claim". When all claims have been entered, click "Submit". You'll see a claims confirmation page which you may print for your records. You may also submit a paper claim; complete necessary information, attached required receipts and return to Sanford Health Plan by mail or fax.

What are some common health expenses eligible for reimbursement?

FSA and HRA funds to pay deductibles and copayments, prescription and over-the-counter medicines with a doctor's prescription, medical equipment such as wheelchairs, walkers and crutches and diagnostic devices like blood sugar test kits. For a full list of eligible and non-eligible medical expenses as defined by IRS code section 213(d), click here.

How do I report a missing debit (Benny) card or request a new card?

From the main page of the Flexible Spending, Health Savings or Health Reimbursement Account Portal, under the "Profile" tab, click "Debit Cards". Then select "Report Lost/Stolen" or "Order Replacement" and provide the requested information.


ID Card Information

When should I receive my ID card?

You should receive your Member ID card within 30 days before policy becomes active.

Will everyone on the plan receive their own ID card?

Depending on your plan, each member may get their own ID card to use, or all family members may be listed on one card. The ID card should only be used by the member who has their name on the card.

What if I've not received, lost or don't have my ID card, but need care?

View your ID card in the portal, or if needed, a provider can also contact us to verify your coverage. If you need to fill a prescription but don't have a copy of your ID card, you will have to pay for the medication in full and submit a claim to Sanford Health Plan for reimbursement. Submit a Claim Form for reimbursement or contact Customer Service to request a form be sent to you.

When should I use my ID card?

Each Member should use the card with their name on it every time they see a provider or fill a prescription.


Pharmacy Information

What medications are covered by the plan?

Information on covered medications (also called a Formulary) can be found in the Member Portal. You can also find information about drug coverage by clicking on "Pharmacy Information". To have your prescription covered by insurance, you must go to a participating pharmacy and show your insurance ID card, unless it is an emergency. You will be responsible for the full cost of the prescription if you go to an out of network pharmacy and it is not an emergency.

How can I compare drug costs?

Once on the OptumRx website, select the blue "Drug search" tool on the far right of the page, or go to "Member tools" at the top of the page and select "Drug information". Type in the drug's brand or generic name, search and then select "Drug Pricing and Information" to determine your cost. Be sure to note any "Coverage alerts" that appear. If shown, this message often contains important information about the drug, cost savings opportunities or how it may be covered under your plan. If you need additional information, please contact Customer Service.

How do I find an in-network/participating pharmacy?

Select "Find a Provider or Pharmacy" in mySanfordHealthPlan, visit sanfordhealthplan.com or contact Customer Service for a list of participating pharmacies in your area.

What If I do not use a participating pharmacy?

To have your prescription covered by insurance, you must go to a participating pharmacy and show your insurance ID card. You will be responsible for the full cost of the prescription if you go to an out of network pharmacy and it is not an emergency. See your plan documents or contact Customer Service for additional information.

What if my medication is not on the list (Formulary)?

If your doctor recommends a drug or medicine that is not on the Formulary, an exception may be allowed. To start the exception process, ask your doctor to contact the Pharmacy Management Department.


Prior Authorization of Services

What is prior authorization (pre-approval or certification)?

It means Plan approval may be required before you see certain providers, or to receive certain services or to fill certain prescriptions. Please note a prior authorization is not a promise the Plan will cover the request, as prior authorization only reviews the request for medical necessity and appropriateness. Coverage of services is based on covered services as outlined in your plan documents.

What services need prior authorization?

Check your policy for specifics, but common examples include outpatient or inpatient procedures or admissions, anesthesia, home health or hospice care, medical equipment, cancer services and treatment, genetic testing, transplants and specialty medication.

What if I need to see a specialist or need behavioral health services?

Work with your primary care provider for a referral, or arrange an appointment on your own. If you have trouble getting an appointment with a behavioral health provider, call the 24-hour behavioral health assessment line at (800) 691-4336. If you choose to see an out of network provider, you must receive pre-authorization from the Plan. Depending on your plan, this may include Mayo Clinic, Rochester, St. Mary's or University of Minnesota. If your request is approved and you receive covered services, claims will be processed at the in-network benefit level.


Provider and Pharmacy Network

Why should I use in-network or participating providers?

Using provider or facility that has partnered with Sanford Health Plan allows you to receive health services at a discounted rate, which saves you money.

How do I know which providers and pharmacies are in my network?

Select "Find a Provider or Pharmacy" in mySanfordHealthPlan, visit sanfordhealthplan.com or contact Customer Service for a list of participating providers or pharmacies in your area.

What if I need emergency care?

In an emergency, call 911 or go to the nearest emergency room, in or out of network. The plan will cover services (per your benefit plan) needed to screen and stabilize Members who are experiencing a medical emergency. Prior authorization is not necessary in emergency situations.

What if I am traveling outside of the United States?

Covered services for medically necessary emergent and urgent care services received in a foreign country are covered at the in-network level. There is no coverage for elective health care/treatment outside the United States. Please note: You may be required to pay for services up front if receiving care outside the U.S. If this occurs, ask the provider for a detailed statement and submit a manual claim for reimbursement.

What if the provider I want to see is not in network?

You can complete a provider nomination form and we will ask the provider to consider participating in our network. Visit sanfordhealthplan.com, the Provider Directory or contact Customer Service submit your nomination over the phone.

What if I choose to see an out-of-network or non-participating provider?

  • If your plan has no out-of-network benefits, you would be fully responsible for the cost.
  • If your plan has out of network benefits, and you choose to go to a non-participating provider when an in network provider is available, claims will be paid per your benefit plan; an out of network copay, deductible and/or coinsurance may apply. In addition, Members may be responsible for any difference between the amount charged (billed by the provider) and the Plan's payment for covered services. Sanford Health Plan will reimburse the maximum allowed amount, which is the lesser of 1) the amount charged for a covered service or supply, or 2) reasonable costs.

Other Common Questions

What if I have a question when Sanford Health Plan is closed?

Please leave a message on our confidential after-hours voice mail or log into mySanfordHealthPlan to send the Plan a secure message. Please remember to provide your name, Member ID number and phone number on all communications. All calls and messages will be returned the following business day.

If I moved or need to update my information, what do I do?

It's very important the Plan has your current mailing address for plan communications, however Sanford Health Plan must receive information updates from your plan's sponsor.

  • If you receive your benefits from your employer, contact Human Resources.
  • If you are a Medicaid Expansion Member, report all changes to your County Social Service Office or contact the North Dakota Department of Human Services Medical Service Division toll-free at (844) 854-4825.
  • If you purchased your plan on the Exchange (HealthCare.gov), all information must be updated through the Marketplace at (800) 318-2596, TTY: (855) 889-4325. Assistance is available 24 hours a day, 7 days a week, except on major holidays.
  • If you purchased your policy at Sanford Health Plan, submit changes in writing to Sanford Health Plan.

Why is it important to have a primary care provider?

Having a primary care provider who knows you well is the best way to keep you healthy; they can assist you in the management of all your health care needs. A primary care provider (PCP) can practice in Internal Medicine, Family Medicine (General Practice), Pediatrics or Obstetrics and Gynecology and you have the right to select a PCP of your choice. If you are ever dissatisfied for any reason with the PCP initially chosen, you can choose another PCP at any time. Customer Service is available to assist you in selecting a provider by providing information on the location of the provider's office and their specialties.

If you see a specialist, we recommend you request a copy of all of your medical records like office notes, laboratory results, x-ray results and/or medication lists to be sent back to your PCP to ensure seamless medical care and treatment. The PCP's responsibilities include: evaluating Member needs, recommending and arranging the services required by the Member, facilitating communication and information exchange among the different providers treating the Member.

What if I need a provider that speaks another language?

If you would like a listing of providers who speak languages other than English, please contact us at (877) 305-5463 or check the Provider Directory for providers that may speak a language other than English.

What if I have other insurance?

If you have another health insurance plan, including Medicare, please fill out a Coordination of Benefits Form or contact Customer Service. We will the other company to make sure both plans work together to process your claims. This will result in more accurate claims processing and you'll save money by maximizing your benefit plans.


mySanfordHealthPlan Frequently Asked Questions


Enrollment Questions

What is mySanfordHealthPlan?

mySanfordHealthPlan offers patients personalized and secure online access to portions of their health insurance records. It helps you securely use the internet to help manage and receive information about your insurance plan. With mySanfordHealthPlan, you may be able to view:

  • Eligibility
  • Benefit and coverage information
  • Claims
  • Prior authorizations
  • Plan documents
  • Resources
  • Links to the Provider and Pharmacy Directory, Pharmacy, Flex and Wellness Portals

How is my information kept secure?

We take great care to ensure your information is kept private and secure. Access to information is controlled through secure access codes, usernames, and passwords. Each user controls their password, and the account cannot be accessed without that password. There is also 128-bit SSL encryption technology with no caching to automatically encrypt your session when you log in. Unlike conventional email, all messaging is done while you are securely logged in.

How do I sign up?

Go to sanfordhealthplan.com/memberlogin to begin the sign up process. Go to "Get Access Here", and select "Request Access for Yourself". Complete the online form to request an activation code. Upon receipt of the activation code by email, return to the website and click "Activate Your Account". Enter the code and complete other fields to complete registration. You will then be asked to create a username and password. If you need assistance with signup, send an email to techsupportmychart@sanfordhealth.org, call (866) 808-5274, or contact Customer Service by calling the number on the back of your ID card.

Who do I contact if I have questions?

For questions regarding your personal health information, contact your clinic. For questions about your insurance plan, contact Sanford Health Plan by calling the number on the back of your Member ID card. If you have questions, send an email to techsupportmychart@sanfordhealth.org, call (866) 808-5274, or contact Customer Service by calling the number on the back of your ID card.

I don't have a Social Security Number. How do I sign up since this information is required?

You may request to enroll by calling the number on the back of your Member ID card. After your identity is verified, you will be emailed a link to enroll without your social security number. Follow the instructions to complete signup within 24 hours after your request the link. (If you request enrollment without a social security number, you will not be able to use any of our online activation/reset features.) If you have questions about enrollment without a social security number, send an email to techsupportmychart@sanfordhealth.org, call (866) 808-5274, or contact Customer Service by calling the number on the back of your ID card.

I received an activation code to complete the signup process, but it does not work. What should I do?

For your security, access codes expire after 30 days and are no longer valid after the first time you use it. If you need help with your activation code, send an email to techsupportmychart@sanfordhealth.org, call (866) 808-5274, or contact Customer Service by calling the number on the back of your ID card.

My activation code is lost, expired or I did not receive it. Can I get another?

If it's been less than 30 days since your account request, your activation code is still valid. Contact Technology Support at (866) 808-5274 or Customer Service by calling the number on the back of your Member ID card to request the code be resent by email.

If it's been more than 30 days since your account request, you can attempt to complete the online signup process again. Or, contact Technology Support at (866) 808-5274 or Customer Service by calling the number on the back of your Member ID card to request a new activation code. You will be required to re-verify your identity to request a new activation code be sent to you.

Is my activation code my user name?

No, your activation code is not your username or password. You will use this code only once to validate your identity when you log into your account for the first time. Activation codes expire after you have used it or after 30 days. When you log in the first time and use your activation code, you will then be asked to create your own unique username and password.

Who do I contact if I have questions?

Contact Sanford Health Plan by calling the number on the back of your Member ID card. If you have questions regarding the site, send an email to techsupportmychart@sanfordhealth.org, call (866) 808-5274, or contact Customer Service by calling the number on the back of your ID card.


Using Your Account

If I see incorrect information, what should I do?

Insurance enrollment information is provided to Sanford Health Plan from your plan sponsor (which may be an employer, government agency, or the Exchange), or your insurance agent on your behalf. Please contact your plan sponsor or agent directly to request changes to your benefit plan.

If I send a message, when can I expect a reply?

You will receive a response to messages sent from mySanfordHealthPlan with one (1) business day.

Can I print information that is displayed?

Yes! There is a "Printer Friendly Page" button that will display in the upper right side of most pages that will print your information in an easy-to-read format.


mySanfordHealthPlan for My Family (Proxy Access)

Can I view a family member's health and/or insurance information?

Yes; this is called proxy access and allows a parent, guardian or authorized representative to log into their personal account and then connect to information regarding their family member. Under "Get Access Here", click "Request Access to Someone Else" and follow instructions to request access. Depending on the type of proxy access you are requesting, his may include completion of an online and/or paper Proxy Consent Form.

Can I ask questions regarding a family member from my account?

No; your account offers direct access to your personal health and/or insurance record and communicating about another individual's information would result in their information being placed in your record. This could potentially jeopardize medical care or insurance activities.

Can my spouse and I share one account?

No; due to the sensitive nature of medical and insurance authorization and claim information, each adult must sign establish his/her own account. If you would like access to someone else's account, you can request access by following the instructions here.

When is proxy access removed?

Once a child turns 18, proxy access for the parents expires. Proxy access for adults expires after five (5) years. Adult users have the ability to revoke access at any time from the "Personalize" screen. Access may also be revoked when confidential care has been provided, parental rights have been restricted, or when required by law.

I once had access to another adult's account and now I do not. What happened?

Users may revoke proxy access to their account at any time. Access to another adult's information expires after five (5) years. If you want to regain access, the adult listed on the account must complete and resubmit the Adult/Teen Proxy Form.


Technical Assistance and Troubleshooting

I forgot my password. What should I do?

Click the "Forgot Password?" link on the sign-in page to reset your password online. If you still have problems, please email us at techsupportmychart@sanfordhealth.org or call (866) 808-5274.

When I try to login, I keep receiving the message "Login unsuccessful". What could be wrong?

The "Login unsuccessful" message appears when either the username or password entered is incorrect. Check if your Caps Lock key is on and also make sure you are using the right username and password. If you need help logging on, please email us at techsupportmychart@sanfordhealth.org or call (866) 808-5274.

I was automatically logged out, what happened?

To protect your privacy and security of your information, if your keyboard remains idle for 15 minutes or more, you will be automatically logged out of your account. We recommend that you log out of each session if you need to leave your computer or device for even a short time.