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ProviderView Quarterly eNewsletter

October 2020

Audio-Only Telehealth Extended Through Dec. 31, 2020

Audio-Only Telehealth 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. 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.

The extension includes audio-only telehealth services. The audio-only extension had been set to expire Aug. 31, but the feedback received from the provider community emphasized the importance of these services in the continuity of care for our members, particularly in the area of mental health.

Coverage for the following CPT codes, which are audio-only by definition, will be supported via telehealth through the end of the year: 98966, 98967, 98968, 99441, 99442 and 99443. The online telehealth CPT table has been updated to reflect this decision and is available online for reference. Please continue to document the type of technology used in conducting telehealth services in your patients’ medical record.

We thank all of the providers who incorporated telehealth into their practices to ensure our members have access to the care that they need. If you have any questions, please feel free to reach out to our Provider Relations team for additional support.

Vaccine Codes and Requirements

Vaccine Codes and Requirements

For providers to get reimbursed for vaccine administration under the Vaccines for Children (VFC) program, they must bill the vaccine CPT code with a “SL” modifier and the applicable administrative service code. The “SL” modifier indicates that the vaccine is state supplied. This requirement is in accordance with national correct coding guidelines.

ICD-10 CM official guidelines: Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given.

Diagnosis-Related Group (DRG) Code Review Reminder

Diagnosis-Related Group (DRG) Code Review Reminder

Avera Health Plans has implemented the new inpatient diagnosis-related group (DRG) codes and completed its annual full-file update for hospital inpatient DRG schedules, which went into effect Oct. 1, corresponding with the annual Center for Medicare & Medicaid Services (CMS) review of the Medicare Severity Diagnosis Related Groups (MS-DRG) weighting factors.

Currently, cases are classified into MS-DRGs for payment under the Inpatient Prospective Payment System (IPPS) based on the following information reported by the hospital: the principal diagnosis, up to 25 additional diagnoses and up to 25 procedures performed during the stay. In a small number of MS-DRGs, classification is also based on the age, sex, and discharge status of the patient.

We pay facilities with MS-DRG payment arrangements for inpatient hospital services on a rate-per-discharge basis. This rate varies by the DRG to which a member’s stay is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs.

Please reach out to the Provider Relations team with any questions.

2020 CAHPS and QHP Results

2020 CAHPS and QHP Results

Each year Avera Health Plans conducts two surveys to gauge member satisfaction: Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Qualified Health Plan Enrollee Experience (QHP).

The CAHPS survey goes to members who purchase insurance through their employer or on their own while the QHP survey goes to members who purchase insurance through the Marketplace.

The data collected provides information on the experiences of our members, and how well the plan and its participating physicians are meeting their expectations. It also serves as a public report card. The CAHPS scores, along with Healthcare Effectiveness Data and Information Set (HEDIS) scores, inform our National Committee for Quality Assurance (NCQA) accreditation and star ratings. The QHP scores, along with HEDIS, inform the star ratings available on both federal and state marketplaces.

After reviewing the data for 2020, Avera Health Plans leadership has decided to focus on three areas for improvement in the year ahead:

  • Customer service/plan administration
  • Enrollee experience with cost
  • Care coordination

Leadership is developing an action plan aimed at improving key drivers influencing these measures.

Behavioral Health Appointment Access Standards

Behavioral Health Appointment Access Standards

To ensure Avera Health Plans members have timely access to services, providers are required to comply with set standards for appointment access.

The minimum appointment access standards are:

Type of Care Access Standard
Routine Care 10 days
Nonlife-Threatening Emergency 6 hours
Urgent Care 48 hours
Emergency Care Immediate - access to 911 and emergency care facilities
Telephone Access 24 hours, 7 days a week, 365 days per year

Each year Avera Health Plans surveys members who had a behavioral health claim in the previous year to assess appointment availability and member satisfaction. Overall, access to timely care improved significantly from 2018 to 2019. Here are some key findings from the survey:

  • 81% of respondents reported being able to see a non-prescriber within 10 days or less for routine visits; this compares to 57% in the previous year.
  • 70% of respondents reported being able to see prescriber within 10 days or less for routine visits; this compares to 56% in the previous year.
  • 72% of respondents were able to see a non-prescriber within 48 hours for an urgent visit; this compares to 33% in the previous year.
  • 75% of respondents were able to see a prescriber within 48 hours for an urgent visit; this compares to 50% in the previous year.