Transition of Care Request

Is My Current Provider in the Sanford Health Plan Network?
The Sanford Health Plan Provider Directory helps you identify which providers are in your plan’s network. Click I’m a Member and enter your last name and member ID to browse providers. If you’re not yet a Sanford Health Plan member, choose I’m a Guest and select a plan type to search for providers in that network. Our customer service team can also help you find in-network providers. Call (800) 752-5863 (TTY: 711).

What if My Provider isn’t Listed?
You can choose to stay with your current provider, but your plan may not cover their services.

If your plan has out-of-network benefits, you can use your coverage. If it doesn’t have those benefits, you’re responsible for any expenses while visiting an out-of-network provider or location.

I’m Currently Being Treated for a Medical Condition. Can I Keep My Current Out-of-Network Provider?
You can keep your current provider if you qualify for a transition of care. See the criteria section below to see if you’re eligible.

An approved transition of care request will allow you to continue care for a set amount of time. You must apply for a transition of care no later than 90 days after your plan’s start date.

My Provider has Left the Sanford Health Plan Network. Are Their Services Still Covered?
If your provider changes network status or no long participates with us, you can apply for a transition of care only if you have a qualifying condition. See the criteria section below to see if you’re eligible.

An approved transition of care request will allow you to continue care for a set amount of time. You must apply for a transition of care within 90 days of the provider’s end date.

If you’d like to start care with an in-network provider, find one using the Sanford Health Plan Provider Directory. This tool will help you find available providers in your plan’s network.

What is a Transition of Care?
With an approved transition of care, you can continue seeing an out-of-network provider even if your plan doesn’t include out-of-network benefits. You’re eligible for a transition of care if you meet one of the criteria listed below.

A transition of care doesn’t last indefinitely. This approval lasts for a set amount of time based on your specific medical or behavioral condition.

What are the Criteria for a Transition of Care Request?
You may be eligible for a transition of care if you:

• Are in the second or third trimester of pregnancy 
• Are receiving cancer treatment or transplant services
• Need a surgery that is already scheduled
• Have a life-threatening mental or physical illness
• Have a physical or mental disability that’s defined as an inability to engage in one or more major life activities provided the disability has lasted or can be expected to last for at least one year or can be expected to result in death 
• Have a physician’s certification that you have an expected lifetime of 180 days or less
• Are receiving services that would be harmful to transition at this point in the treatment

How do I Apply for a Transition of Care?
Download a transition of care request form here or submit an online form below. The form must be signed by the person requesting the transition of care. If they are a minor, we require a guardian’s signature.

Submit the form to:
Sanford Health Plan
Attn: Transition of Care
PO Box 91110
Sioux Falls, SD 57109

Fax: (605) 312-8910

Transitions of care don’t apply to yearly physicals or routine medical care. Please don’t complete a form if you, a spouse or a dependent wants to continue with an out-of-network provider for primary care.

Completing the form doesn’t guarantee authorization or payment for the requested services.

How Will I Know if My Transition of Care Request is Approved?
You will receive a letter explaining the outcome of your request by mail.

Submit Form