Transparency in Coverage

Providing you information about your health benefits is our goal so you can make the best health-related decisions based on your needs. Below is an overview of our business practices when it comes to claims, cost-sharing, and coverage.

The information we are providing below can be found in your policy (Certificate/Evidence of Coverage), Member Guide or Summary of Benefits and Coverage. We are highlighting the basics so you can quickly understand commonly used health insurance terms and policies.

  • Out-of-Network Liability – how we process or pay your claim
  • Member Submitting Your Own Claim
  • Grace Periods and Claims Pending
  • Consequences of Not Making My Monthly Premium Payment
  • Consequences of Paying More Than the Full Monthly Premium Due
  • Medical Necessity, Preauthorization Timeframes and Member Responsibilities
  • Drug Exception Timeframes and Member Responsibilities
  • Explanation of Benefits – how your claim is processed
  • Coordination of Benefits – when a member has more than one health plan
  • Surprise Billing & Good Faith Estimates

Out-of-Network Liability (Balance Billing)

When you don’t visit an in-network provider, the coverage and cost-sharing for care received with non-participating providers varies by plan type. Out-of-network coverage is the lowest level of benefits when covered services are received by non-participating providers. You will have to pay an out-of-network deductible and coinsurance which are higher than and separate from your in-network deductible and coinsurance amounts.

Some health services may not be covered if they are received from a non-participating (out-of-network) provider. In addition, non-participating providers may balance bill you (bill you the balance) for any differences between their billed charges and the amount we allow when those differences exist whereas participating providers have agreed to accept the amount we allow as full settlement of their charges.

Exceptions apply when services with non-participating providers are obtained for emergency services or when a participating provider has recommended a referral to a non-participating provider and we have authorized the referral in advance at the in-network benefits level.

To find an in-network, participating provider with your plan:

  1. Login or use your mobile app.
  2. Click “My Provider Directory.”
  3. Identify if you want to search a person or facility (both referred as a provider).
  4. Click “Continue,” and you will be provided options to narrow down your search.

After you enter the required options, a list of in-network providers and a map will appear for you to view.

NOTE: It is your responsibility to:

  • Contact the provider to verify new patient status, location and confirm participation in our network.
  • Verify your benefit eligibility.
  • Understand what your benefits are covered/not covered.

You can do this by viewing your policy (sometimes referred as your Certificate/Evidence of Coverage) and/or your Summary of Benefits and Coverage, both found in the member portal on the “My Benefits” page after you log in. These documents will also show you the exact cost-sharing responsibilities for out-of-network coverage for your plan.

Member Submitting Your Own Claim

A claim is a request for payment that you or your health care provider submits to your health insurance carrier for costs for health care services and/or supplies provided to you by a provider.

When you go to a participating provider, the provider will file claims for you. When you receive a bill or invoice from a participating provider for a service you received, you don’t need to send us a claim.

If you have a question about whether your provider’s office has filed your claim, you can log in to access your claims, our mobile app Avera Health Plan or call our Customer Care Center at 888-322-2115.

If you receive health services from a non-participating provider, you will need to ask your provider if they will file the claim for you.

If the non-participating provider will not file a claim for you, you must file the claim (proof of loss) within 12 months of the date you received health care services. We will not pay claims (proof of loss) filed more than 12 months after the date of service.

  1. Use the most current claim form available. Avera Health Plans will only accept the following completed claims forms listed below.
  1. Please make copies of your documents. It is a good idea to keep a copy (or keep the original and send us a copy) of any documents.
  2. Mail the claim form and itemized bill to main office:
    Avera Health Plans
    5300 S. Broadband Lane
    Sioux Falls, SD 57108

Note: If we have to request additional information, this may delay the processing of your claim. We will send payment on your claim to the provider.

Grace Periods and Claims Pending

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual health care plans, if you do not pay your premium on time, you will receive a 31-day grace period.

  • A grace period is a time period when your plan will not terminate even though you did not pay your premium.
  • Any claims submitted for you during that grace period will be pended.
  • When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.
  • If you do not pay your delinquent premium by the end of the 31-day grace period, your coverage will be terminated.
  • If you pay your full outstanding premium before the end of the grace period, we will pay all claims for covered services you received during the grace period that are submitted properly.

If you are enrolled in an individual health care plan offered on the Health Insurance Marketplace and you receive an advance premium tax credit, you will get a three-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended.

If you pay your full outstanding premium before the end of the three-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period.

If you do not pay all of your outstanding premium by the end of the three-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.

Consequences of Not Paying the Full Monthly Premium Due (Retroactive Denial of Claims)

In agreement with the laws of the state of South Dakota, if you don’t pay your monthly premium on time, we can review your paid claims to determine if it was processed correctly. If we identify we paid the provider for services and you had not paid your monthly premium payments in full or on-time, we can recover the over payment from you or the provider. Making sure your premiums are paid on time is one way to help prevent a retroactive denial of a claim.

Consequences of Paying More Than the Full Monthly Premium Due (Recoupment of Over-payments)

If we receive more than the amount due for your monthly premium or we over-billed you for your premium, we will apply the credit to go toward future billing unless we receive a request to send a refund check.

To request a refund check:

Contact our Customer Care Center by emailing Service@AveraHealthPlans.com or call us toll-free at 888-322-2115 (or TTY 711 or 800-877-1113), Monday – Friday, 8 AM-5 PM CT.

We will mail you the refund check within 45 calendar days of the date of the request.

Medical Necessity, Preauthorization Timeframes and Member Responsibilities

Certain medical services will require you to ask your provider to call for a preauthorization. For a list of these medical services requiring a preauthorization, follow the guidelines below. If your provider does not call, services will not be covered.

Note: We do not reward individuals who conduct review for issuing denials of coverage. We will not provide rewards for medical management decision-makers to encourage denials of appropriate coverage. Incentive to under-utilize is also not rewarded.

Preauthorization means the process when specific services, supplies and procedures for care and treatment are approved by us BEFORE you receive the services. Preauthorization does not guarantee benefits. Your benefits are subject to all conditions of your policy. You can view the most current list of medical services requiring a preauthorization with your plan in your member portal. After you log in, click My Benefits to find the Preauthorization List link.

Note: To request in-network benefits for health services from a non-participating provider your provider must submit medical records for review to Medical Management Department.

To request a preauthorization:

  1. Your provider will need to contact us to obtain preauthorization for certain procedures and services. The back of your member ID card will identify the website address for you or your provider to view the services requiring a preauthorization.

Note: You also need to obtain preauthorization if you are requesting in-network benefits for health services from a non-participating provider.

  1. We will review the request providing the information for medical necessity.
  2. When a decision is made, you and your provider will receive a letter that states the decision.

Note: If the health services are approved, the letter will list the services that have been authorized (for example, office visit only or office visit and lab tests). We will respond within 15 days of receipt of the request.

  1. Please read this letter carefully so you know what services have been authorized.

Note: If your request for preauthorization is urgent (meaning a delay could jeopardize your life, health or ability to regain maximum function or would cause severe pain that could not be adequately managed without the requested care or treatment), we will respond within 24 hours of receipt of the request.

For further assistance or if you have any questions concerning preauthorization, call our Medical Management team toll-free at 888-605-1331.

Drug Exception Timeframes and Member Responsibilities

Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by Avera Health Plans through the formulary exception review process. The member or provider can submit the request to us by faxing the Pharmacy Formulary Exception Request form (pdf). If the drug is denied, you have the right to an external review.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision.

An IRO review may be requested by a member, member's representative, or prescribing provider by mailing, calling, or faxing the request form:

Avera Health Plans
5300 S Broadband Lane
Sioux Falls, SD 57108

Or call Population Health Services toll-free at 888-605-1331.

For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form.

Explanation of Benefits

The Explanation of Benefits (EOB) provides information about how your claim was processed; it is not a bill or an invoice. Your claims and EOBs can be viewed on our website or mobile app after Avera Health Plans receives the claim from your provider.

On the bottom of your EOB (example pdf), the following definitions are available:

  • Date of Service: The date you received services.
  • Service Code: This code identifies the medical service you received.
  • Diagnosis Code: This code identifies your medical condition.
  • Amount Billed: The amount your provider has charged for services received.
  • Network Savings: The amount reflects the in-network discount for visiting a participating provider for services.
  • Amount Not Covered: The amount billed or services not covered by insurance.
  • Reason Code: An explanation of the amount not covered or your notice when you have reached your deductible will also appear below the claim detail.
  • Your Deductible: The amount applied to your total deductible balance.
  • Primary Insurance: The amount your other insurance paid.
  • Your Co-Pay: The fixed amount you are required to pay at the time of service.
  • Your Coinsurance: Your share of the costs of a covered health care service calculated as a percent after the network savings. For example: you pay 20%, the plan pays 80%
  • Your Plan Pays: The amount paid by your employer or health plan.
  • You Owe: An invoice from your provider will be sent separately to explain payment options and where to make a payment.

Note: You may have paid your co-pay at your visit and this will be reflected in your provider's invoice.

To view your EOB, and the most recent claims processed, log into the member portal, click My Health Plan/Claims to search.

Your EOB also shows you any amount that you may owe. The Claims and Eligibility page will also give you year-to-date balances of your deductible(s) for your in- and out-of-network usage.

You can go paperless by requesting that your EOBs no longer get mailed to you and you will receive an email when the EOB is available to view on the mobile app or after you login.

To go paperless:

  1. Log into the member portal.
  2. In the upper right corner, Click My Preferences.
  3. Click Communication Preferences.
  4. Click the check box under Email for EOB.

Note: You will only be able to access EOBs for yourself. If you are the subscriber of the policy, you will have access to dependents under the age of 18.

If you want access to your adult dependents (for example, your spouse, legal guardian, insurance agent, college child), we require you to complete the form Authorization for Access of Health Information (pdf), or your dependent may grant you access in their portal through the My Family/Permissions page..

Note: For online access, all members listed on the form must log in and register, including the member authorizing the release of information, before Avera Health Plans can process.

When You Have More Than One Health Plan (Coordination of Benefits)

When you are covered by more than one health insurance carrier or plan, our state law permits the health plans to follow a process called coordination of benefits. In order for us to process claims with more than one plan, please complete and submit the Coordination of Benefits Form (pdf).

After we receive the completed and signed form, the coordination of benefits will determine how much each health plan should pay each claim:

  1. The plan that pays first is the primary plan.
  2. The plan that pays second is the secondary plan.

The goal is to make sure that the combined payments of all plans don’t add up to more than your covered health care expenses.

Surprise Billing & Good Faith Estimates

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Learn more about surprise billing (pdf) or how to receive a good faith estimate (pdf).

Machine-Readable Files

Pursuant to South Dakota Codified Law 58-17K-5, we have made our South Dakota pharmacy prescription drug file in a machine-readable format that includes negotiated rates with in-network pharmacies.

In compliance with Transparency in Coverage Rules, we have made our files in a machine-readable format that includes negotiated rates for in-network providers and historical allowed amounts and billed charges for out-of-network providers. Avera Health Plans is working closely with its vendor to prepare Machine Readable Files for posting to its website to meet the Transparency in Coverage rules. We anticipate being able to post these files soon. For more information, email ahpedi@avera.org.

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