FARGO, ND (Valley News Live) – The North Dakota Insurance Department says an examination of Sanford Health Plan (SHP) has uncovered non-compliance with state and federal laws.
The examination, which took place from April 2022 to October 2023, reviewed the actions of Sanford Health Plan from 2016 to 2020 to ensure policies and procedures followed applicable laws.
“The essential function of the North Dakota Insurance Department is to ensure that consumers are treated fairly and respectfully by their insurance company,” said Insurance Commissioner Jon Godfread. “A market conduct examination is a way of looking at specific cases to see how consumers have been treated and if the law was followed.”
The examination found non-compliance in the following areas of SHP:
- Claims processing
- Mental and behavioral health and substance abuse claims, including Mental Health Parity and Addiction Equity Act compliance
- Comparative analyzes for Non-Quantitative Treatment Limitations (NQTLs) and Quantitative Treatment Limitations (QTLs) associated with the Mental Health Parity and Addiction Equity Act (MHPAEA)
- Telehealth services coverage and claims
- Independent review procedures
- Coordination of benefits with auto insurance
- Medicare Supplement products
- Insurance fraud reporting
- Pharmacy Benefit Management contracts
The North Dakota Insurance Department says SHP agreed with most of the examination findings and will work to correct the errors. A copy of the full SHP examination report is available here.
The examination is required under the North Dakota Century Code, which requires regular market conduct examinations for health insurance companies with at least 25 percent of the market share. Sanford Health Plan is one of two health insurance companies that currently meet this criterion. A market conduct examination of Blue Cross Blue Shield of North Dakota was completed in 2019.
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