FOR PROVIDERS

Verify Eligibility

To verify eligibility, exclusions, and covered services, please call our Benefit Advocacy team.

Monday - Friday 7am-6pm MT

prior authorization

Our plans do not currently require prior authorization.

However, we encourage you to contact us for detailed information about what services are covered under your patient's plan.

Planstin's Minimum Essential Coverage (MEC) plans cover preventive care and basic services. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's plan documents at the time of service.  Listed below is an example of covered benefits for some of our plans to give you an idea of how a claim from your office might be paid.

MEC PLAN INFORMATION FOR PROVIDERS

This information is for example purposes and does not guarantee eligibility or payment.

CLAIMS

FIRST CLASS MAIL

Planstin (SDS)

PO Box 21747

Eagan, MN 55121

ELECTRONIC

Payer ID

65241

NETWORK

We use the MultiPlan/PHCS Specific Services network.

IN NETWORK

OUT OF NETWORK

Most, but not all, MEC plans use reference-based pricing (RBP) for out-of-network claims for covered services.

APPEALS

 Please include the following information in your written request:

• Member Name & Date of Birth
• Member ID & Group Number
• Claim Number
• Date of Service
• Name of Provider
• Reason for appeal

A provider, member, or their authorized representative has 180 days following receipt of an Adverse Benefit Determination within which to request a Standard Internal Appeal. You may request an appeal by sending a written request to the following address:

Planstin Administration

ATTN: Claims/Appeals

1506 S. Silicon Way, Suite 2B

St. George, UT 84770

All Comments, documents, records, and other information submitted and relating to the claim will be reviewed without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. The appeal will be conducted by an appropriately named fiduciary of the plan who is neither the individual who made the Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of such individual. The named fiduciary will conduct a completely new review, not considering the initial determination.

INDEPENDENT EXTERNAL REVIEW

If you still disagree with our decision and all the plan's internal appeal processes have been exhausted as outlined in the member's plan documents, you are entitled to request an Independent External Review of our decision.

You or your authorized representative must file the request within 4 months after the date of receipt of a notice of an Adverse Benefit Determination or Final Internal Adverse Benefit Determination.

EXPEDITED APPEALS

If your patient's situation meets the definition of "urgent" under the law, you may ask for and Expedited Appeal. If you, as their healthcare provider, believe that the patient's condition could seriously jeopardize their life, health, or ability to regain maximum function or would subject them to severe pain that cannot be adequately managed without care of treatment by waiting up to 30 calendar days for a decision, you may ask for an Expedited Appeal.

Expedited Appeals may be requested in writing or by calling our Benefit Advocacy team at 888-920-7526. If you make a request in writing, see the mailing address and information requirements above.

We will respond to requests for an Expedited Appeal within 72 hours from the date we receive the request.

To verify benefits, please call our Benefit Advocacy team.

Monday - Friday 7am-6pm MT