Sanford Health Plan, Attention: Appeals
PO Box 91110, Sioux Falls, SD 57109-1110
Phone: (800) 601-5086 Fax: (605) 312-8910
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
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
Required Documentation: Original EOP
Code Review: The provider feels the denied claim was coded
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.