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ProviderView Quarterly eNewsletter

June 2020

Please Take Our Annual Provider Survey

Please Take Our Annual Provider Survey

Each year Avera Health Plans asks providers to offer feedback using a short survey.

Please submit your answers to help us better serve you.

Thank you for your help—we look forward to hearing from you!

Telehealth Expansion During the National Public Health Emergency for COVID-19 Pandemic Extended Through Dec. 31, 2020

Telehealth Expansion During the National Public Health Emergency for COVID-19 Pandemic Extended Through Dec. 31, 2020

In March, Avera Health Plans and DAKOTACARE announced modifications to our reimbursement policy for telehealth services to preserve access to care while preventing the further spread of the novel coronavirus. While the return to normalcy is underway, it remains important that a conservative approach be followed as the “new normal” begins to emerge.

The original announcement on telehealth during the pandemic was effective with dates of service March 17 through June 14. Avera Health Plans and DAKOTACARE will continue to support this expanded access to telehealth services through Dec. 31, 2020, which allows enhanced care access and improved health care quality with no cost to our members.

As a recap, these provisions include:

  • Expansion of the list of CPT® codes normally permitted to be performed via telehealth. Our standard Telehealth Policy is a compilation of all of the standard CPT® codes permitted by CMS (notwithstanding a Public Health Emergency declaration) and all of the CPT® codes listed in CPT® Appendix P. View the current, complete list of telehealth-eligible services.
  • Reimbursement rates at the equivalent in-person (non-facility) fee schedule values.
  • Waiver of member cost share regardless of whether the telehealth service was related to COVID-19 or not.
  • Relaxation of the HIPAA requirements and technology platforms permitted for telehealth consistent with the prior announcement posted by the Health and Human Services Agency including use of telephone (audio-only) technologies where appropriate. The audio-only provision ends Aug. 31, 2020. Beginning Sept. 1, 2020, only those telehealth services which use real-time interactive audio-video technologies are considered eligible for reimbursement.

We will continue to monitor the situation and adapt any additional CPT® codes that may be announced by CMS. With each of the prior releases of CPT® code expansions announced by CMS, the changes were made retroactive to March 17 and any prior claims that may have been denied were reprocessed accordingly. Telehealth claims for services billed outside of the approved CPT® codes will continue to be denied. We encourage you to check the online listing frequently for any updates.

As a reminder, for accurate reimbursement of telehealth claims, follow the billing standards outlined in our Telehealth Reimbursement Policy including:

  • Use of the telehealth place of service code 02.
  • Do not use modifier GT.
  • Modifier 95 is acceptable but not required.
  • When use of audio-only telephonic technology is used, it should be documented as such in the medical record.
  • Telehealth services require the same level of medical record documentation as any equivalent face-to-face encounter or service. The totality of the communication and information exchanged between the health care professional and patient during the course of the telehealth service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

This notice is applicable to Avera Health Plans fully-insured lines of business, group numbers beginning IA, SD or NE and to DAKOTACARE HMO business. Self-funded employer groups are being presented with this position on telehealth extension as a recommended option, but each self-funded employer group will make their own benefit determination.

We will update our COVID-19 resources page with additional details as the self-funded employer groups give us their benefits position or you can contact our Customer Care team:

  • Avera Health Plans: 1-888-322-2115, 8 a.m. to 5 p.m. CT, Monday through Friday
  • DAKOTACARE: 1-800-325-5598, 8 a.m. to 5 p.m. CT, Monday through Friday

Medical Drug Coverage Update – Preferred Medical Drug Products

Medical Drug Coverage Update – Preferred Medical Drug Products

Effective June 1, 2020, Avera Health Plans and DAKOTACARE have implemented new pharmacy drug coverage policies and updated existing preauthorization policies to reflect the addition of preferred drug products covered under the medical benefit. In most instances, the preferred drug product involves the use of a biosimilar product prior to use of the brand-name reference product.

The following is a list of therapeutic classes that now have preferred drug products. Please refer to your provider portal to access the full pharmacy coverage and preauthorization policies.


Short-Acting GCSF (granulocyte colony stimulating factor)

Policy Number: SS-RX-PCP-006-01 (NEW)

Avera Health Plans and DAKOTACARE require the use of preferred short-acting GCSF biosimilar products prior to coverage of non-preferred products. Members with a new diagnosis or who are new to a specific drug therapy will be required to use the preferred biosimilar products. Preferred products include:

  • tbo-filgrastim (Granix®)
  • filgrastim-sndz (Zarxio®)

Long-Acting GCSF (granulocyte colony stimulating factor)

Policy Number: SS-RX-PCP-007-01 (NEW)

Avera Health Plans and DAKOTACARE require the use of preferred long-acting GCSF biosimilar products prior to coverage of non-preferred products. Members with a new diagnosis or who are new to a specific drug therapy will be required to use the preferred biosimilar products. Preferred products include:

  • pegfilgrastim (Neulasta®,Neulasta® Onpro)
  • pegfilgrastim-cbqv (Udenyca™)

Hyaluronic Acid Derivatives

Policy Number: SS-RX-PCP-003-04 (Updated)

Avera Health Plans and DAKOTACARE require the use of preferred hyaluronic acid derivative products prior to coverage of non-preferred products. Members with a new diagnosis or who are new to a specific drug therapy will be required to use the preferred products. Preferred products include:

  • Monovisc
  • Orthovisc
  • Synvisc or Synvisc One

Infliximab

Policy Number: SS-RX-PA-033-04 (Updated)

Avera Health Plans and DAKOTACARE require the use of the preferred infliximab-abda (Renflexis™) biosimilar product prior to coverage of non-preferred products. Members with a new diagnosis, who are new to a specific drug therapy, or seeking authorization for continued therapy, will be required to use the preferred infliximab-abda (Renflexis™) biosimilar product.

IMPORTANT NOTE on Prescription Authorizations

IMPORTANT NOTE on Prescription Authorizations

DAKOTACARE Administrative Services (DAS) no longer performs prescription authorizations for South Dakota State Employee Health Plan. Authorizations are performed by CVS Caremark.

  • CVS Caremark Fax (non-specialty): 1-888-836-0730 | Phone: 1-866-443-1185.
  • Please update records for all members of the SD State Employee Health Plan.

Radiology Notification Requirements Ending Effective July 1

Radiology Notification Requirements Ending Effective July 1

Avera Health Plans and DAKOTACARE are ending the requirements for radiology notifications effective for dates of service on or after July 1, 2020.

What does this mean for effective for service dates on or after July 1, 2020?

  1. Your office/facility no longer needs to submit a radiology notification form to Avera Health Plans or DAKOTACARE.
  2. Your office/facility can schedule patients for imaging procedures without contacting Avera Health Plans or DAKOTACARE.
  3. Standard claims submission processes will be followed and radiology imaging claims will be paid without notification.
  4. This change does NOT apply to Smithfield Foods, Inc., members. Current PA submission requirements to eviCore will continue.
  5. This change does NOT apply to State of South Dakota Employee Plan members. Please continue to follow current requirements of State of South Dakota Employee Plan

Radiology notification submissions for dates of service on or after July 1, 2020, will be returned to the provider with a copy of this article letting them know that the notification requirement has been retired.

We appreciate your patience, flexibility and understanding during this unprecedented time. For any questions or concerns, please contact our Provider Relations team or our Customer Service Center for more information.

Reimbursement Policies Aligned for Administrative Simplification

Reimbursement Policies Aligned for Administrative Simplification

With the organizational integration of Avera Health Plans and DAKOTACARE, work has been completed to fully align the reimbursement policies for both plans as shared policies to reduce variation and create administrative simplification.

Avera Health Plans has always maintained the reimbursement policies on our provider portal for ready access to the provider community. The policies cover common reimbursement-related topics applied in the adjudication of claims. Work is under way to create access to these same policies behind security on the DAKOTACARE provider portal.

The policies apply to both plans uniformly and once posted to the DAKOTACARE provider portal, they will be accessible from either plan’s website. Medical policies, pharmacy policies and dental policies have all been aligned already. So while we remain separate insurance plans, the alignment of the reimbursement policies in subject matter, content, format and accessibility should make working with either plan easier for you and your staff.

Fee Schedule Update

Fee Schedule Update

As a reminder, Avera Health Plans will implement new codes for 2020 with the implementation of our existing values for the Universal Schedule as of Jan. 1 this year. Avera Health Plans completes a full file update for our provider fee schedules by July 1 each year to correspond with the annual changes performed by CMS to the Relative Value Units (RVU) and Medicare rates.

Additional new codes are added when released. The comprehensive update to the RVU and CMS values are performed each year by July 1 for most of our provider agreements. If you have any questions related to updates that may impact your fee schedule, please contact the Provider Relations team for assistance.

COVID-19 Response: Connecting with High-Risk Members

COVID-19 Response: Connecting with High-Risk Members

During the COVID-19 pandemic, we are reaching out to high-risk members to ensure their well-being.

Health coaches, nurses and member health advocates are calling members with a history of heart disease, cancer and diabetes to check in during this difficult time. “The first thing we’re emphasizing is the importance of staying connected to your primary care provider using telehealth services or telephone visits, which are currently covered benefits,” said Preston Renshaw, MD, Chief Medical Officer of Avera Health Plans and DAKOTACARE.

“We want our members to meet their health goals while practicing social distancing and preventing further exposure to COVID-19. We also want to make sure they are staying current with their medications and preventive services and help troubleshoot any issues they may have in their home or community environments.”

Most importantly, however, these check-ins offer a point of connection during a time of isolation.

“We want our members to know we truly care about them, and that we are here advocating on their behalf; it’s our mission,” Dr. Renshaw said. “If they need financial or social assistance, we can help connect them with the right resources.”

The member response has been one of gratitude and appreciation:

“[We] were so impressed to receive a call from Avera…offering many ways to help protect [ourselves] from this sneaky, scary virus. [We] were doing several, but [now know] several more we can be doing. Very helpful! You have some very caring employees at your company, and we sure appreciate you!"

Take Advantage of These Provider Manual Features

Take Advantage of These Provider Manual Features

Avera Health Plans includes important information to review in the Provider Manual, which is available on the Avera Health Plans website:

  • How to refer patients to complex case management services
  • How to obtain utilization management criteria
  • Affirmative statement about incentives
  • Practitioner rights in the credentialing process
  • Member rights and responsibilities