Fillable Provider Claim Reconsideration Request

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Provider Claim Reconsideration Request

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Sanford Health Plan, Attention: Appeals
PO Box 91110, Sioux Falls, SD 57109-1110
Phone: (800) 601-5086 Fax: (605) 312-8910
HP-3535 04-21
Provider Claim Reconsideration Request
To Submit a Claim Reconsideration Request: Provide the information shown below and
complete a separate request for each claim. Return with the associated Explanation of
Payment (EOP) and/or supporting documentation via the Provider Portal, fax (605) 312-
8910 or mail.
INCOMPLETE SUBMISSIONS WILL BE RETURNED UNPROCESSED
Provider Information
Provider Name:
Contact Name:
NPI Number:
Phone Number:
Fax Number:
Email Address:
Contact Address:
Member/Claim Information
Member Name:
Date of Birth:
Member ID Number:
Date(s) of Service:
Claim Number(s):
Type of Reconsideration Request
Duplicate Claim: A first time claim submission that denied as a
duplicate filing, or the service lines on the claim were denied as a
duplicate.
Required Documentation: Original EOP
Code Review: The provider feels the denied claim was coded
correctly.
Required Documentation: Provide explanation/rationale below.
Timely Filing: A first time claim submission that denied for timely filing.
Timely filing is the number of days shown below from the date of service,
date of inpatient discharge or paid date on the primary EOP:
-
180 days for participating providers
-
365 days for non-participating providers and any provider who cares for
North Dakota Medicaid Expansion Members
Required Documentation: Screen-print from the billing system showing the date the
claim was sent to Sanford Health Plan. If filed electronically, the name of the
clearinghouse used with evidence the claim was accepted by the Plan without error
must also be included.
HP-3535 04-21
Request for Additional Information: A first time claim submission that denied for
additional information, due to an unlisted/unspecified procedure code that
was submitted without supporting documentation or a procedure code that
was not submitted with operative or anesthesia notes, a pathology report,
and/or office notes.
Required Documentation: Provide explanation/rationale below and relevant clinical
documentation.
Other: Network, Scope of practice, experimental /investigational denials or
other to request a claim reconsideration for topics not mentioned above.
Required documentation: Provide explanation/rationale in the comments below.
Comments:
*You do not use this form for the following requests:
Retrospective Authorization Request – Please submit through the provider portal
if the services is on the Prior Authorization list. You have 60 days from date of
service for submission.
Corrected Claim- Resubmit the claim electronically or fax to (605) 328-6840.
Coordination of Benefits- Fax the other carrier’s EOB/EOP to (605) 328-6840.
Incorrect Reimbursement- Fax to Provider Relations at (605) 328-
7224.
MultiPlan or Data iSight Reimbursement- Call MultiPlan at (800) 950-7040 or Data
iSight at (866) 835-4022 to file a reimbursement appeal.
Signature
Signature of Person Requesting Reconsideration
Today’s Date
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Provider Claim Reconsideration Request

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Completed 19 May 2021

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