If you have a Sana First health plan, some care requires a referral or approval before you receive services. If Sana Care denies or limits a requested referral, diagnostic test, or Transition of Care request, you may receive a Pre-Service Adverse Benefit Determination.
What is a Pre-Service Adverse Benefit Determination?
A Pre-Service Adverse Benefit Determination is a formal written notice explaining that a request for care has been denied or restricted before you receive that care.
There are three types:
- Full denial: Your requested referral or diagnostic test is denied.
- Partial denial or scope restriction: Part of your request is approved, but the approved care differs from what you requested—for example, fewer visits, a shorter timeframe, or a smaller lab panel.
- Transition of Care denial: Your request to continue existing care when joining the plan is denied.
A Pre-Service Adverse Benefit Determination is different from a claim denial for services you have already received.
What does the notice include?
Your Pre-Service Adverse Benefit Determination notice includes:
- The specific reason for the denial or restriction.
- The plan provisions used to make the decision.
- Your appeal rights, submission instructions, and applicable deadlines.
- Information about requesting documents, guidelines, or clinical protocols used in the decision at no charge.
- Instructions for requesting an expedited appeal if urgent clinical care is involved.
If you haven’t received your notice or need another copy, you can contact Sana Care directly.
How do I appeal a Pre-Service decision?
If you disagree with the decision, you can submit a First Level Appeal to request a formal review.
First Level Appeals must be filed within 180 days. Review your notice for the applicable deadline and instructions on what information and documentation to include.
Mail your standard Pre-Service appeal to:
Sana Benefits
Attn: Pre-Service Appeals
3723 Greenville Ave STE 13463
Dallas, TX 75206
Customer Support can help you understand the submission instructions. An appeal requests a review of the decision; it does not guarantee approval.
If your care needs are urgent, use the expedited appeal options below instead of standard mail.
What if I need an urgent review?
You or your provider may request an Expedited Appeal when your treating clinician certifies that waiting for the standard 30-day appeal timeframe could:
- Seriously jeopardize your life or health.
- Jeopardize your ability to regain maximum function.
- Subject you to severe pain that cannot be adequately managed without the requested care.
Your treating clinician must certify the clinical urgency.
How to request an Expedited Appeal
You or your provider may submit the request verbally or in writing:
- Call: (833) 726-2123
- Email documentation to: hello@sanabenefits.com
- Use this email subject line: URGENT EXPEDITED APPEAL - [Patient Name] - [Member ID]
The Plan will issue a determination as quickly as your medical condition requires, but no later than 72 hours after receiving the expedited appeal request.
The 72-hour decision window applies to expedited appeals, not standard appeals.
Can I request the information used to make the decision?
Yes. You can request the documents, guidelines, or clinical protocols used to make the decision at no charge.
Please contact Sana Care directly for help obtaining those materials.
Have questions? We've got you covered.
- Log in to view account details.
- Search FAQs in our Help Center.
- Connect with Customer Support directly through the chat icon on most Sana pages or call us at (833) 726-2123 Monday through Friday, 7 AM to 7 PM Central.