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ProviderView Quarterly eNewsletter

December 2020

Note of Thanks

Note of Thanks

To our provider community, As 2020 draws to a close, and we reflect on all that has happened, words can’t express our gratitude and appreciation for each of you. All we can say is thank you.

Thank you for your creativity and adaptability in standing up new processes and protocols. Thank you for the sacrifices – seen and unseen – that you and your families have made. Thank you for going above and beyond in support of our members and our communities.

We are grateful for your partnership.

We wish you and your loved ones a happy holiday season; though it may look different than years past, may it be filled to the brim with love and rest.

With gratitude,
Avera Health Plans and DAKOTACARE

Avera Health Plans Will Transition to New Claims Processing System

Avera Health Plans Will Transition to New Claims Processing System

In mid-2021, Avera Health Plans will transition to a new claims processing system by HealthEdge Inc. called Health Rules Payor. DAKOTACARE will not be affected by this change at this time.

The new system will allow Avera Health Plans to offer an integrated provider and consumer experience, bringing operational efficiencies while also elevating the quality of care provided to our members.

The system has two key components:

  1. HealthRules Payor will be the operating system for all lines of business, including fully-insured policies and third-party administration services. HealthRules Payor is the platform for processing services for member enrollment, claims adjudication, customer service, reporting and other business process services.
  2. HealthRules CareManager will be the integrated tool for utilization management, case management and disease management tracking.

Overall, the HealthRules system will facilitate a seamless, integrated experience for case management, referral management, intake and routing, medical review, concurrent review, discharge planning, appeals and inpatient/outpatient authorization. Our staff will have access to the critical information necessary to create an enhanced member and provider experience, and increased automation will allow a faster turnaround in responding to provider inquiries, contract maintenance and fee schedule updates.

As the transition date draws closer, Avera Health Plans will prepare providers for any changes they may encounter. If you are not currently submitting claims electronically to Avera Health Plans, please consider reaching out to your clearinghouse to get set-up today.

Pharmacy Update: 2021 Preauthorization List Changes

Pharmacy Update: 2021 Preauthorization List Changes

Effective January 1, 2021, the following list of non-preferred drugs will require preauthorization.

Therapy Class Brand J code
Granulocyte Colony Stimulating Factors Fulphila Q5108
Granulocyte Colony Stimulating Factors Udenyca Q5111
Granulocyte Colony Stimulating Factors Neupogen J1442
Granulocyte Colony Stimulating Factors Leukine J2820
Granulocyte Colony Stimulating Factors Nivestym Q5110
Viscosupplements Durolane J7318
Viscosupplements GenVisc 850 J7320
Viscosupplements Hyalgan J7321
Viscosupplements Hymovis J7322
Viscosupplements Euflexxa J7323
Viscosupplements Gel-One J7326
Viscosupplements Gelsyn-3 J7328
Viscosupplements TriVisc J7329
Viscosupplements Sodium Hyaluronate Soln J7331
Viscosupplements Triluron J7332
Viscosupplements VISCO-3 J7333

Effective January 1, 2021, the following list of drugs will no longer require preauthorization.

Medical Benefit Chemotherapy Prior Authorization Removal
Chemotherapy agent J code
Abraxane/Taxol/PACLitaxel J9264/J9267
Adcetris J9042
Adriamycin/ DOXOrubicin J9000
Adrucil/ fluorouracil J9190
Alkeran/melphalan injection J9245
bleomycin J9040
Busulfex/busulfan J0594
Camptosar/irinotecan J9206
CISplatin J9060
cladribine J9065
cyclophosphamide J9070
cytarabine J9100
dacarbazine J9130
DAUNOrubicin J9150
DaunoXome J9151
Eloxatin/oxaliplatin J9263
Fludara/fludarabine J9185
Gemzar/gemcitabine J9201
Hycamtin/topotecan J9351
Idamycin/IDArubicin J9211
Ifex/ifosfamide J9208
Mitosol/Mutamycin/mitoMYcin J9280
Oncovin/Vincasar/vinCRIStine J9370
Paraplatin/CARBOplatin J9045
Taxotere/DOCEtaxel/Docefrez J9171
Toposar Etopophos/etoposide J9181
Trisenox/arsenic trioxide J9017
Vidaza/AzaCITIDine J9025
vinBLAStine J9360

Pharmacy Benefit Chemotherapy Prior Authorization Removal
Chemotherapy agent
Alkeran/melphalan tablets
etoposide capsules
Oxsoralen Ultra
tretinoin capsules

Expanding Access to Home Phototherapy for the Management and Treatment of Plaque Psoriasis

Expanding Access to Home Phototherapy for the Management and Treatment of Plaque Psoriasis

Psoriasis is an immune-mediated inflammatory disorder of the skin that affects approximately 2.2 to 3.1 percent of the adult population in the United States. Chronic plaque psoriasis is the most common form of the disease, occurring in over 80 percent of the cases.

Data shows that 60 percent of patients who use light therapy two to three times per week are likely to achieve a 75 percent improvement in their disease (Psoriasis Area Severity Index score (PASI 75). However, a significant limitation to the use of phototherapy is the requirement for a patient to find time to drive to a clinic that provides phototherapy. This inconvenience leads to transition from from topical therapy to systemic biologic therapy.

Systemic biologic therapy is an effective treatment modality for plaque psoriasis. However, these agents suppress patients’ immune system, leaving them at risk for infection. Phototherapy home units offer an opportunity to increase access to phototherapy, potentially avoiding adverse medication effects of systemic therapies.

To that end, the following CPT codes will no longer require preauthorization, effective January 1, 2021:

CPT Code Description
E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less
E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel
E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel
E0694 Ultraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer, and eye protection


  1. Menter A, Strober B, Kaplan D, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol 2019;80:1029-72.
  2. Elmets C, Lim H, Stoff B, el al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol 2019;81:775-804.

Eviti® Contract Terms for DAKOTACARE Administrative Services

Eviti® Contract Terms for DAKOTACARE Administrative Services

Since 2012 DAKOTACARE Administrative Services, Inc. has partnered with Eviti®, a clinical leader in oncology decision support to provide a comprehensive review of oncology drugs and radiation-oncology services. Beginning January 1, 2021, these services will be managed by the Avera Health Plans and DAKOTACARE Administrative Services clinical pharmacy team.

Currently, the Avera Health Plans’ clinical pharmacy team performs preauthorization review of oncology drugs for 70,000+ covered lives and evaluates the requested treatment plans in accordance with National Comprehensive Cancer Network (NCCN) published guidelines.

The clinical pharmacy team is connected with specialty pharmacies, board-certified oncology pharmacists, and board-certified oncology providers, thus providing further integrated care delivery for patients. This collaboration will allow for a more streamlined preauthorization experience, while maintaining a comprehensive clinical review process, complete with provider peer-to-peer discussions, to ensure the appropriate therapy is being delivered to the patient.

With this change, all existing Eviti® preauthorizations will be honored though the end of the current expiration date.

All future chemotherapy preauthorization requests may be submitted via the Chemotherapy Preauthorization request form.

2020 Physician Directory Accuracy Report

2020 Physician Directory Accuracy Report

In order to provide our members with accurate information on in-network physicians and help them avoid barriers to access, it’s important for Avera Health Plans to provide accurate information in the physician directory. Avera Health Plans validates the data that appears in the provider directory on an ongoing basis, and the data is analyzed annually to identify opportunities for improvement. At a minimum, validated information includes:

  1. Office address
  2. Office phone number
  3. Hospital affiliations
  4. Accepting new patients
  5. Awareness of physician office staff of physician’s participation in Avera Health Plans’ networks

During February 2020, Avera Health Plans submitted 500 queries to randomly selected physicians with 263 responses received. Results from the survey showed:

Area Specific Area Monitored Numerator Denominator Percent Accurate Goal Met (>90%)
1 Office Location 245 265 92.45% Yes
2 Phone Number 233 265 87.92% No
3 Hospital Affiliation 230 265 86.79% No
4 Accepting New Patients 237 265 89.43% No
5 Awareness of physician office staff of physician’s participation in the organization’s networks 256 265 96.60% Yes

Avera Health Plans directory analysis met the accuracy goal for office location and awareness of physician office staff of participation in Avera Health Plans’ networks. Avera Health Plans did not meet the accuracy goal in phone number, hospital affiliation and accepting new patients.

It is important that practitioners or their administrative credentialing staff validate this information during re-credentialing so updates or changes can be added to the directory. In addition, please note that our website allows for electronic notification of these updates. Please use our Provider Change Request page to alert us of any demographic changes.

Thank you for your assistance in helping us keep this information current to better serve our members.

Provider Communication: New Process for 2021

Provider Communication: New Process for 2021

The pandemic required us all to adjust the way we do business – and it’s prompted us to evaluate how we can best communicate with our provider community.

Going forward, we will no longer send a quarterly ProviderView newsletter; instead, we will be sending updates on an as-needed basis to ensure you have the information you need quickly and efficiently.

Our communications will still come under the ProviderView heading, but from; please be sure to add the address to your “safe senders” list. And, as always, you can find the latest updates and information online.

Please don’t hesitate to email our Provider Relations team.

New Contact Information for Provider Relations Specialist Maggie Schmidt

New Contact Information for Provider Relations Specialist Maggie Schmidt

Please update your contact information for Provider Relations Specialist Maggie Schmidt to Maggie Pauley. She can now be reached at or

And please join us in offering congratulations and best wishes on her recent marriage.

Scott Jamison Retiring

Scott Jamison Retiring

As of Dec. 26, Scott Jamison will be retiring from the Provider Relations Department at the Avera Health Insurance Division.

We appreciate the numerous contributions Scott made in his 20 years with DAKOTACARE and the Avera Health Insurance Division, and the strong relationships he forged with our provider community during those years. Scott will be missed by all of us! We wish him the best in his much-deserved retirement.

After Dec. 26, please contact Mike Dooley for any issues where you would have went to Scott in the past.

Telehealth Services Updates for 2021

Telehealth Services Updates for 2021

We enter 2021 with the promise of new COVID-19 vaccines that we all hope will bring an end to the pandemic and a return to normalcy.

It’s expected the public health emergency declaration that was renewed Oct. 23 will be renewed again in January. The U.S. Department of Health & Human Services (HHS) will take that step, and it’s likely to remain active through the first half of 2021.

Here are the updates to the Avera Health Insurance Division’s position on telehealth for Jan. 1, 2021.

Telehealth Cost Share

Cost-sharing for telehealth services has been waived since the beginning of the public health emergency, regardless of whether or not the service was COVID-19-related. Beginning Jan. 1, normal cost-sharing provisions will return with the exception that cost-sharing will continue to be waived for services related to COVID-19 testing. As an Insurance Division, we are electing to continue to waive cost-share for mental health services received through telehealth.

Telehealth Fee Schedule Parity with In-Person Services

We will continue to reimburse telehealth services at the higher, non-facility values of our fee schedule, making the telehealth reimbursement equivalent to the in-person visits for the same code. This will continue as an added measure of support to the provider community until further notice.

Telehealth Services via Audio-Only Technology

We will continue to permit telehealth services via audio-only technology while the public health emergency remains in effect. As a reminder, when audio-only technology is used, it should be documented in the medical record.

Telehealth Services and HIPAA Compliance

The Office for Civil Rights (OCR) at HHS is responsible for enforcing certain regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act, to protect the privacy and security of protected health information, namely the HIPAA Privacy, Security and Breach Notification Rules (the HIPAA Rules).

Providers are encouraged to perform all telehealth services using technology platforms that meet all of the standards required for privacy and security by the HIPAA rules. OCR has stated that it will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good-faith provision of telehealth during the COVID-19 nationwide public health emergency.

Telehealth Eligible CPT Codes

We will be carrying our current list of telehealth-eligible CPT codes forward into 2021 until further notice.

Our teams will monitor for any additions or deletions by CMS; we’ll amend or update our list as necessary. Our current telehealth-eligible CPT code list is posted online in our COVID-19 resources page. Codes that were added as a temporary measure during the public health emergency are expected to be retired at some point in 2021. We will announce, using ProviderView and other channels, any future reductions to the telehealth-eligible CPT code list. We encourage providers to monitor the online list; check it frequently as changes or updates can occur at any time.