Provider Perspective

Itemized Bill Review changes
Sanford Health Plan performs Itemized Bill review in accordance with our policy, Inpatient/Outpatient Unbundling of Routine Services and Supplies. Claims that meet the threshold will be required to submit an itemized bill. If an itemized bill is not submitted with the claim, it will be requested. When an itemized bill is not received within 14 days of request the claim will be denied with CO 16 – N26 (Deny for Itemized Bill). Please note if it is determined that the charges between the claim received and itemized bill do not align, your claim may also be denied.

Effectively immediately, please send Itemized Bills to:

Email: SHPPaymentIntegrity@SanfordHealth.org

Fax: 1-605-705-2821

Please be sure to include Payment Integrity IBR in the subject line. All emails should be sent securely to ensure compliance with standard HIPAA regulations. In an effort to ensure that all affected providers were aware, a notice was sent to known contacts for this process at the time of the change and all letters, emails, or faxes sent out going forward were updated with the new information.

Be aware that as of June 1, 2023, any itemized bills still being sent to the Provider Relations email address or fax number will be sent back to the provider without being worked.

Claim Status Tool

As more businesses utilize 3rd parties to call on claim statuses or verify member benefits, our call wait times have increased. In an effort to build better self-service tools, last year we introduced the Claim Status tool - this is a feature that does not require anyone to sign in to look up basic claim processing details. We think of it as a game changer when you just need to know a status and don't have the time to call in or log in! You can find the link on our website here.

When using this tool, you will need to know 3 pieces of information:

Either a) Your facility NPI OR b) Your tax ID
An ID - this can be either the Sanford Health Plan claim ID OR the patient ID that you put on claims when you submit them.
Either a) Earliest date of service OR b) Billed amount

Once you've entered in the 3 key items, you can verify you are not a robot and results will populate. You will the receive the following information:

Sanford Health Plan Claim ID #
Net Payable amount
Payment status (Pending, sent, disbursed, etc.)
Payment ID number
Payment Date
Date Claim was received in our system

Additional information to help you verify this is the claim you were looking for will be available on this screen. It includes:

Billed Amount
Claim Type
Submitted ID (Your facility's submitted patient ID)
Facility Name
Rendering Provider name (if applicable).

Pharmacy Clinical Pearls

The goal of this section is to provide you with information on newly approved medications, updated medication indications or warnings, new generic approvals, and other miscellaneous pharmacy “pearls”.

On January 20th, another SGLT2 inhibitor Brenzavvy™ (bexagliflozin) was FDA approved to improve glycemic control in adults with type 2 diabetes mellitus as an adjunct to diet and exercise.

The recommended dose is 20 mg once daily, taken in the morning, with or without food. This is the only dosage form/strength currently available.

It is not recommended if eGFR is less than 30 mL/min/1.73 m2.

Zavzpret™ (zavegepant) is a calcitonin gene-related peptide receptor antagonist that received FDA approval on March 9^th. It is indicated for the acute treatment of migraine with or without aura in adults. It is not indicated for the prevention of migraines.

It is a nasal spray that is dosed as 10 mg given as a single spray in one nostril, as needed (max of 1 dose in 24 hours).
No significant pharmacokinetic interactions were observed when zavegepant was concomitantly administered with sumatriptan.

Takeda is set to lose exclusivity on Vyvanse® in August of this year. While the drug manufacturer has filed at least four patent cases in an effort to maintain exclusivity, there will likely still be generic competition starting in August. Vyvanse® coupon cards are still currently valid through the end of the calendar year.
Humira® is another drug that is losing exclusivity and already has eight biosimilars expected to hit the market in July. One biosimilar, Amjevita™, is Amgen’s biosimilar to Humira® and has already been available since January.

Itemized Bill Audit Appeal

The itemized bill audit has changed over the past year and one of the ways we’ve been striving to work with you on these charges has been to simplify the appeal process. There is now a specific appeal form to be used when creating a reconsideration for these claims. It is located in the Provider Portal under the Forms and Documents link in the Quick Links section. This form is a required document, along with any other supporting documentation when you submit a Provider Reconsideration. Once you’ve completed this form, you’ll want to follow the steps to open a Claim Reconsideration and select the Payment Integrity subtopic.

Provider Directory

Ensuring a member of Sanford Health Plan finds care in network is as easy as can be with our Find a Doctor tool! Initially built as a member tool, providers are welcome to use it to verify their own status for a member or to assist a member if they need to referred on to different care.

From the Sanford Health Plan home page, click the button that says "Find a Doctor".

There are 2 different options - to sign in as a member or as a guest. We always recommend using the Sign in as a Member option as no personal health information is needed or provided. It will give you that exact member's network rather than a general network. All you need is the member's name and member ID.

Once you are in, you are able to use different criteria to verify providers of different types available in network for that member's plan. Options include searching by regions, address, state, type of physicians or facilities, and other criteria.

Provider Perspective

Claim Status Tool

Pharmacy Clinical Pearls

Provider Educational Series

Itemized Bill Audit Appeal

Provider Directory

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