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Key Resources

Here’s where you can find insurance coverage details:

  • Benefits high-level summary: Check out the coverage overview in your plan’s Summary of Benefits and Coverage.
  • Benefits details: See the finer details of your insurance plan coverage, called the Summary Plan Description or Evidence of Coverage for most members – or the Outline of Coverage for Medicare Supplement Insurance.

Where do you find these documents? Log into the member portal or check your welcome or enrollment kit. If you have questions, you can contact us.

Network Provider FAQ

It’s important to know how provider and facility choices can impact your health care costs.

What's an in-network provider?

To help manage health care costs, you can get discounts on services and medical procedures when you receive care from Avera Health Plans in-network providers. These include physicians, hospitals, facilities and other health care providers participating in the our network.

These in-network benefits are available with more than 2,000 primary care physicians and 4,300 specialists and other health care providers available in your region.

What's an out-of-network provider?

Out-of-network providers are physicians, hospitals and health care providers not participating in the Avera Health Plans network. If you receive medical care from an out-of-network provider, you’ll pay more for those services. Because this balance will not go toward your in-network deductible, you’ll pay more overall throughout the year.

Find a Provider

Members should log into the member portal for specific details.

More Coverage Details

Prescription Drug Benefits

See more

Preventive Care Coverage

see more

After-Hours and Emergency Care

see more

Health Insurance When You Travel

see more

COVID-19 Coverage

see more

Virtual Visits

see more

LiveNOW Well-Being Program

see more

Preauthorizations – How to Know If You Need Approval

In some circumstances, our approval (or preauthorization) is required before you receive a specific service, procedure, drug or medical supplies – in order for us to provide coverage.

If you fail to receive a required preauthorization, you’ll be responsible for paying the entire billed charge.

If you're not finding what you need, contact us for help.

Note that preauthorization does not guarantee benefits and the preauthorization list is subject to change. Benefits are subject to all conditions of your health insurance policy.

Preauthorization Process for Health Plan Members

  1. Your provider must check our provider resources for preauthorization requirements for medical procedures, imaging and prescription drugs. If a preauthorization is required, the provider must submit the appropriate preauthorization form and clinical documentation to us.
  2. Our clinical review team will review the request and a letter will be mailed to you and your provider with the approval or reason for denial within 15 calendar days.
  3. If approved, the letter will list which specific services, procedures and/or drugs have been approved. Please read the letter carefully so you know what services your provider has been authorized to perform.

Preauthorization Process for Medicare Supplement Insurance

  • Standard Medicare Supplement Plans: You do not need a preauthorization to use any facility.
  • Select Medicare Supplement Plans: You do not need a preauthorization if you use a facility listed in the Network Hospital Directory for Select Plans (pdf). If the facility is not listed in the directory, your physician will need to call for a preauthorization of services. This needs to be approved before you receive services at the out-of-network facility.

Urgent Preauthorizations

Our clinical team will respond in 24 hours if your situation is urgent – meaning that 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.

  • In the case that we are unavailable – such as on weekends, holidays or after business hours – your provider must contact us no later than two business days after you receive the services, supplies or procedures.
  • Learn about emergency and urgent care coverage.
  • Learn about your insurance when you travel.

More Coverage FAQ

How can I learn about next year’s health insurance plans?

New health insurance plans and details are available during open enrollment season.

How do I know if my prescription drug is covered?

If you’re a member already, be sure to log into the member portal to check your plan’s drug coverage. We also share a list online of the prescriptions covered for various drug tiers.

What is an explanation of benefits (EOB)?

After each medical visit, you’ll receive an explanation of benefits (EOB) in the mail with information about your claim, how it was processed and how much you may owe. The EOB is not a bill or invoice. Your provider will send you a separate invoice.

You can view all your claims in the member portal and in the Avera Health Plans Mobile App. Once logged in, you can opt into receiving EOBs and claim information by email rather than mail. Just go to Profile and then select Paperless EOB.

Need help with a chronic condition?

Managing a chronic disease or complex illness can feel like a full-time job. That's why our dedicated team of Nurse Case Managers help you navigate with our care management programs. We offer this expertise at no cost to any member requiring additional support on their health care journey. Our specially trained nurses:

  • Assist with care coordination, finding a physician or specific specialist within your provider network.
  • Collaborate with your primary care provider.
  • Help with communication between you and your providers to ensure appropriate, timely and cost-effective medical services.
  • Provide care option information to help you make informed decisions, improve your quality of life and reduce medical expenses.
  • Educate you on wellness, preventive services, health conditions, community resources and any other concerns.

To learn more or see if you qualify, contact our Nurse Case Management team at 888-605-1331.

Need Something Else?

See all of our member resources online.

Member Resources Member Portal

Or contact our Customer Service team.

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