MEMBER
MESSENGER Summer 2019
In each issue: Provider Updates Benefit Information Finding a Specialist
How to find support
when life gets you down
Formulary updates Prior authorization
What is subrogation? 10 tips to quit tobacco FOR GOOD sanfordhealthplan.com
Why you need
a primary care doctor Preventive health guideline updates
NEW
enhanced online wellness portal
How to find support when life gets you down When you feel overwhelmed by all of life’s ups and downs, Sanford Health Plan is there for you. The Behavioral Health Team offers support and reminds you that you’re not alone. We all feel this way at some point, and your health can be affected by these feelings. This includes things like where you live, work and play, which may include money worries, family problems, access to transportation, competing priorities and lack of time. These stressors can leave you feeling like you have nowhere to turn. Your mental health includes understanding who you are, life events, and emotional health, all which can be connected to your physical well-being. Sanford Health Plan is proud of the behavioral health assistance and benefits we offer to our members. Our team of Behavioral Health and RN case managers have many resources to help with those times when life seems to have the upper hand. Whether you have mental health or physical conditions affecting you, call Sanford Health Plan at (877) 652-1847 to speak with one of our case managers. We are here for you.
Sanford Health Plan’s formulary, or medication list, is reviewed and updated throughout the year. The most recent update occurred in April 2019. Visit sanfordhealthplan.com or log in to the member portal to find the most current coverage document. 2
Prior authorization Sanford Health Plan requires prior authorization for medical services including (but not limited to) all inpatient stays, select outpatient surgeries and durable medical equipment. For a full list of services requiring prior authorization, please visit sanfordhealthplan.com/members/prior-authorization. To obtain authorization, contact Utilization Management by calling the number on the back of your member ID card. Prior authorization is the responsibility of the member even though most providers will submit the request on behalf of the member. Authorization requests should be submitted at least three working days prior to the date of service for a scheduled service. Routine requests may take up to 14 calendar days for review and determination. For urgent services, an expedited review can be requested.
What is subrogation? Subrogation is the process of attempting to obtain reimbursement for medical services if another party is at fault for an injury or illness. Sanford Health Plan will verify if another company or person should be responsible for claims submitted with certain diagnoses. For example, certain traumas related to a car accident or a work related injury can at times be submitted for claims.
Optum will send you a letter on behalf of Sanford Health Plan to confirm if someone else may be responsible for reimbursement or if Sanford Health Plan should cover your care. If you receive a call or letter asking you to verify information, please respond right away to ensure claims are not denied. Subrogation Forms can be returned by mail in the included envelope or completed online at icc.optum.com. Contact Optum at (800) 529-0577. 3
10 Tips to Quit Tobacco
FOR GOOD 1
Determine your reasons
2
Set a quit date
Tell others
Find new ways to manage stress Practice a healthy activity in its place
6
Carry healthy snacks or sugar-free gum
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3
Drive a different route to work
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10
Get support from a coach
Envision your life free of nicotine
Take advantage of your Sanford Health Plan benefits
Through the NDPERS Tobacco Cessation Program, current employees of the State of North Dakota, North Dakota University System, district health units and Garrison Diversion Conservation District and their dependents age 18 and older with NDPERS health coverage are eligible to receive a debit card to pay for out-of-pocket quitting expenses. • $200 for office visits and co-pays • $500 for FDA-approved medications Call (877) 737-7730 or go to sanfordhealthplan.com/ndpers to enroll or learn more.
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Why you need a primary care doctor There are many reasons you might need to see a doctor. Sometimes, you need to see a doctor for a routine checkup or preventive care such as immunizations. Other times, you might need treatment when you're sick. No matter how healthy you are, having a primary care doctor is beneficial. A primary care doctor will: • Learn about you and your health history • O ffer preventive care and screenings to help you stay healthy and out of the ER • Recognize risks before you get sick • Treat your illnesses • Coordinate your care with specialists Benefits of having a primary care doctor: • C are you can trust from a provider who knows you and your medical history • A partnership for life-long health • Evaluation and treatment for urgent health problems • C oordination of care when transitioning from pediatric to adult providers as well as specialty providers • Maintaining preventive care and screenings • R eminders for testing and treatment for chronic health conditions • H elp understanding and adapting to life transitions related to health and aging A visit with a primary care provider costs less than an emergency room visit. If everyone saw a primary care provider, the U.S. would save an estimated $67 billion every year. *
DON’T HAVE A PRIMARY CARE DOCTOR? Call Sanford Health Plan at (800) 499-3416 for help choosing an in-network primary care physician. 6
* https://www.primarycareprogress.org/primary-care-case/
Preventive health guideline updates All updates start July 1, 2019. Sanford Health Plan is adding coverage for: • C ervical cancer screening every five years (additional coverage is provided when HPV testing is completed and not in conjunction with a pap test) • C omprehensive metabolic panel (CMP) once per year • O besity screening and counseling for adults • O steoporosis screening for women ages 65 or older or women under age 65 who are at risk • P reventive skin cancer counseling for patients ages 6 months to 24 years • S yphilis screening in all pregnant women • U nhealthy alcohol use screening and counseling in all adults ages 18 and older Sanford Health Plan is removing coverage under the preventive health guidelines for: • A nnual Basic Metabolic Panel (BMP) on 12/31/19
For more information, visit sanfordhealthplan.com or call (800) 499-3416. Preventive health benefits are provided as listed, unless your plan document(s) state otherwise. Please see your Certificate of Insurance (COI) for full details on how your preventive care will be covered.
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Provider Update To see the most current list of providers, visit sanfordhealthplan.com/ memberlogin
Benefit Information For additional Health Plan benefit information, visit sanfordhealthplan.com/ memberlogin or call Customer Service at (800) 499-3416.
Finding a Specialist If your doctor refers you to a specialist, but the specialist is not available as soon as you would like, you have options. Ask the clinic if a similar specialist is available or call Sanford Health Plan Customer Service.
NEW enhanced
online wellness portal The enhanced online wellness portal will retain some of the same activities members enjoy today along with new features including: • C ommunity message boards to encourage co-workers in their health pursuits • I mproved mobile app experience and fitness device connectivity
CONTACT US
• M onthly sessions with education, goal-tracking, health quizzes and games
memberservices@ sanfordhealth.org
• M ore daily wellness trackers like sleep and salt intake
(800) 499-3416
• Q uestion and answer opportunities with physicians through Doctor Chat
TTY: (877) 652-1884 Language Line: (800) 892-0675
• W orkout videos and healthy recipes to boost physical well-being Support your health and wellness journey with Sanford Health Plan’s online wellness portal.
Access the wellness portal inside your mySanfordHealthPlan account. SVHP-2765 Rev. 7/19