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ProviderView Quarterly eNewsletter

January 2020

Avera Health Plans and DAKOTACARE Have Moved

Avera Health Plans and DAKOTACARE Have Moved

The Avera Insurance Division campus previously occupied two buildings off of 49th Street and Elmwood Avenue. On Nov. 18, 2019, Avera Health Plans and DAKOTACARE employees moved to a new Sioux Falls location. Our new physical address is as follows:

  • 5300 S. Broadband Lane
    Sioux Falls, SD 57108

We hope the following FAQ clarifies what changes with this move, and what remains the same. If you have any additional move-related questions please contact our Provider Relations team.

Q. Will any email addresses, phone numbers or fax numbers change?

A. No, email addresses, phone numbers and fax numbers do not change with our move. This applies both to individuals and departments.

Q. Will the Avera Health Plans address for paper claims change?

A. In an effort to reduce the number of paper claims received, we request that you file electronically if possible. If you need to submit a paper claim to Avera Health Plans we ask that you continue sending them to the following address: PO Box 381506, Birmingham, AL 35238.

Q. Will the DAKOTACARE address for paper claims change?

A. Yes, historically paper claims for DAKOTACARE were mailed directly to the old office on 49th and Kiwanis. Moving forward any paper claims for DAKOTACARE should be sent to our new address. Again, we request that you file electronically if you are able.

Q. What address should I use for correspondence not related to claims?

A. Please use our new address when mailing any non-claims related correspondence such as Provider Requests for Reconsideration and ERA/EFT requests. These documents can also be sent via fax and email. All forms posted on our websites have been updated to reflect the new mailing address, 5300 S. Broadband Lane, Sioux Falls, SD 57108.

Q. How about electronic payer ID numbers; are these changing?

A. No, electronic payer ID numbers for both Avera Health Plans (46045) (38310 – Smithfield Foods) and DAKOTACARE (DAK01) will remain exactly the same.

Late Notification & Retro Authorization

Late Notification & Retro Authorization

Avera Health Plans and DAKOTACARE require preauthorization or notification of certain services to be faxed in to the Clinical Review department. To ensure accurate payment of claims, please submit the prior authorization or notification to:

Avera Health Plans: Fax to 1-800-269-8561 or send secure e-mail to HealthServices@AveraHealthPlans.com

DAKOTACARE/DAS: Fax to 1-605-274-3279 or send secure e-mail to HealthServices@DAKOTACARE.com

  • Radiology Notifications will be accepted up to 15 business days after the service has been rendered. If a notification is received after 15 business days, the provider will receive a notice of late notification. Any request for reconsideration should be submitted directly to Provider Relations via the following methods:
    • Avera Health Plans: Fax to 605-322-4540
    • DAKOTACARE/DAS: Mail to 5300 S. Broadband Lane, Sioux Falls, SD 57108
  • Inpatient Admission Notifications must be received within 48 hours of admission to the facility. Failure to notify will result in a denial of claims payment with 100 percent provider liability.
  • All other services requiring prior authorization must be received before the service is rendered. Authorizations may take up to 14 days to process.

For questions regarding Clinical Review practices, please call 1-888-605-1331.

Policy Change: Continuous Glucose Monitors

Policy Change: Continuous Glucose Monitors

Avera Health Plans and DAKOTACARE expanded coverage of continuous glucose monitors (CGMs) for most members beginning Jan. 1, 2020.

Currently, CGMs are covered under the plan’s medical benefit, which means members must obtain supplies from a durable medical equipment (DME) supplier Effective Jan. 1, 2020, members will now be able to obtain CGMs at in-network retail pharmacy locations.

Members who choose to obtain CGMs from a retail pharmacy will pay the pharmacy plan’s preferred brand co-pay or coinsurance. Membesr who continue to obtain CGM supplies through DME providers will continue to pay medical deductible and/or coinsurance.

Members who choose to receive CGMs from a pharmacy will have access to the following CGM systems: Dexcom G5®, Dexcom G6®, and FreeStyle Libre®.

Expanded access to CGMs through retail pharmacy locations is expected to be more cost effective and convenient for Avera Health Plans and DAKOTACARE members. Members currently utilizing CGM devices have been notified via letter explaining their options regarding this expanded access.

NOTE: Smithfield members, UMR members, DAKOTACARE-Individual members, and state of South Dakota members will not be affected by this change.

Avera Health Plans Clinical Review Affirmative Statement about Incentives

Avera Health Plans Clinical Review Affirmative Statement about Incentives

Clinical Review decision-making is based only on appropriateness of care and service along with the existence of coverage. Avera Health Plans does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for clinical review decision makers do not encourage decisions that result in underutilization.

Avera Health Plans Quality Improvement Program

Avera Health Plans Quality Improvement Program

We receive questions occasionally about what actions Avera Health Plans takes to ensure quality. The Avera Health Plans Quality Improvement Program is designed to objectively and systematically monitor and evaluate the quality, appropriateness and effectiveness of care.

The current goals and objectives include:

  • Maintaining a Quality Improvement structure and process that supports continuous improvement including measurement; analysis; intervention; and re-measurement for issues involving patient safety, quality of care, and outcomes
  • Defining clinical quality and building organizational capabilities to support the achievement thereof
  • Systematically monitoring and evaluating key indicators and measures to detect trends and identify opportunities to improve quality of care and service to members
  • Identifying, prioritizing and developing interventions that target opportunities for improvement, identifying variance from performance goals and benchmarks, developing and testing improvement and evaluation plans, and regularly re-evaluating quality improvement efforts
  • Developing data-driven disease and complete case management strategies to improve practitioner and member compliance with clinical and/or behavioral health guidelines and standards
  • Ensuring a system of continuous quality improvement communication that is timely and reports through appropriate channels to appropriate individuals
  • Monitoring ongoing compliance with applicable accreditation and regulatory standards
  • Enhancing relationships with physicians by engaging in collaborative process improvements and supporting them to improve clinical quality and to better manage the care of targeted members
  • Serving and improving clinical outcomes for members with complex health needs, disabilities, and severe and persistent mental illness through our complete case management program; monitoring and improving access to care; and monitoring and improving continuity and coordination of care across multiple settings
  • Validating quality of care trends and communicating trends to Avera Service Lines
  • Providing education to members and network behavioral health care practitioners regarding appointment availability standards
  • Implementing a population health program with data analytics tools
  • Integrating adverse events reporting with Avera Health System initiatives

Introducing Provider Relations Specialist Steven Grogan

Introducing Provider Relations Specialist Steven Grogan

The Avera Health Plans and DAKOTACARE Provider Relations team is excited to welcome Steven Grogan as a new Provider Relations Specialist.

Steven graduated from the University of South Dakota in 2013 with a master’s degree in Health Care Administration. He has been a Provider Relations Representative for Avera Health Plans since June 2016, so you may have talked to Steven on the phone with a claims, reimbursement or contracting question in the past.

As a Provider Relations Specialist, Steven is responsible for initiating the contracting and credentialing process of new and existing network providers. He communicates regularly with providers and their staff to ensure Avera Health Plans and DAKOTACARE are doing everything possible to make provider practices run smoothly so that physicians are able to focus on patient care.

In his new expanded role Steven is looking forward to meeting more providers and staff in travels around our network.

Happy New Year from Avera Health Plans and DAKOTACARE

Happy New Year from Avera Health Plans and DAKOTACARE

We wish you and your loved ones a happy, healthy 2020!

avera health plans and dakotacare team