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ProviderView Quarterly eNewsletter

April 2020

Telehealth Services and COVID-19: Temporary Relaxation of Certain Telehealth Requirements

Telehealth Services and COVID-19: Temporary Relaxation of Certain Telehealth Requirements

Avera Health Plans and DAKOTACARE have been fielding questions around the coverage of telehealth services during the current COVID-19 pandemic. The situation has been very fluid. A Public Health Emergency was declared Jan. 31 and The Coronavirus Preparedness and Response Supplemental Appropriations Act was signed into law March 6. On March 17 Health and Human Services (HHS) and the Office for Civil Rights (OCR) announced the relaxation of enforcement of HIPAA Privacy rules to empower providers to serve patients during this national public health emergency. The details of this most recent announcement can be found online at the Department of Health and Human Services.

In light of these developments, and to promote continued access to care and minimize contact exposure, Avera Health Plans and DAKOTACARE will follow suit with the HHS guidance on relaxation of the telehealth HIPAA requirements inclusive of audio-only phone calls effective March 17, 2020, through June 14, 2020 (90 days). During this time, we will also temporarily map place of service (POS) code 02 for telehealth, to pull from the higher, “non-facility” level of the professional fee schedule. This measure is meant as an additional means of supporting the provider community during this unprecedented disruption so the provider will be paid the same as if the member had an in-person encounter.

Members receiving telehealth services from participating providers during this period will also have their normal cost-share waived regardless if the telehealth visit is directly related to COVID-19 or not. Normal telehealth HIPAA requirements, fee schedule mapping and benefits would be reinstated again effective June 15 unless an extension of these provisions is announced.

These provisions will apply to our fully insured lines of business. While we are sharing what we are doing with our self-funded employer group clients for their consideration, each self-funded employer group client will make its own decisions on telehealth benefits administration during this emergency period. At the time this is being released, we know that the Avera Health Employee Health Benefits Fund and Smithfield Foods have approved this same approach for their employee plans. For any other self-funded employer group clients, please call us for confirmation of their benefits.

Providers will be expected to follow all normal CPT coding and billing guidelines inclusive of complete medical record documentation. The record should document the means by which the telehealth service was provided and billed with place of service (POS) code 02. Providers who have the capability to deliver telehealth using HIPAA compliant, real-time interactive audio-video technology may append those services with modifier 95 although it will not be required.

Due to the dynamic and evolving nature of this national public health emergency, policies could be subject to change, particularly in the event that additional guidance is issued from any state or federal regulatory authority. We have created Avera Health Plans and DAKOTACARE COVID resource pages for our providers; we will keep them updated with new information and guidance as it becomes available.

Our Provider Relations staff are available to help answer further questions related to this announcement. If you have questions and want to reach out, please see our team territory map and contact information below.

COVID-19 Response: Connecting with High-Risk Members

COVID-19 Response: Connecting with High-Risk Members

During the COVID-19 pandemic, AID is 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 as well as 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."

Credentialing Changes Implemented Jan. 1, 2020

Credentialing Changes Implemented Jan. 1, 2020

As part of the ongoing activities to align administrative procedures and policies between the operations of Avera Health Plans and DAKOTACARE, the credentialing polices, known as the “Credentialing Plan” for both organizations went through a thorough review in the last quarter of 2019. While the Credentialing Plans undergo review annually as part of normal operations, the review in 2019 focused on identifying and aligning the Credentialing Plans for consistency. Once those differences were identified, the Credentialing Committees for both organizations made recommendations on alignment that were then presented to the respective Board of Directors for approval. The new, uniform Credentialing Plan was approved in December and subsequently adopted by both health plans effective Jan.1, 2020.

Here is a summary of the key differences and changes implemented to the Credentialing Plans.

Physician Assistants

Avera Health Plans: In order to qualify for credentialing, physician assistants had to be certified by the National Commission on Certification of Physician Assistants (NCCPA).

DAKOTACARE: Physician assistants did not require certification to qualify for credentialing.

The Avera Health Plans standard of requiring NCCPA certification was adopted and incorporated into the DAKOTACARE Credentialing Plan.

Physical Therapists

Avera Health Plans: In order to qualify for credentialing, the physical therapist must have either a doctorate degree in an appropriate discipline from an accredited college or university, a master’s degree in an appropriate discipline from an accredited college or university in addition to five years clinical experience, or a bachelor’s degree in addition to 10 years clinical experience.

DAKOTACARE: Physical therapists with master’s or bachelor’s level licenses did not need to meet the additional requirements on years of clinical experience.

The Avera Health Plans standard of requiring the additional years of clinical experience for master’s or bachelor’s level licenses was adopted and incorporated into the DAKOTACARE Credentialing Plan.

Licensed Professional Counselors

Avera Health Plans: Licensed professional counselors in South Dakota who were licensed and in good standing were qualified for credentialing.

DAKOTACARE: Licensed professional counselors in South Dakota must hold the mental health (LPC-MH) or qualified mental health practitioner (LPC-QMHP) licensure level.

The DAKOTACARE standard of requiring licensed professional counselors to hold the additional MH or QMHP licensure level was adopted and incorporated into the Avera Health Plans Credentialing Plan.

Any providers who already had a credentialing application under consideration at the end of 2019 would have had their application completed under the 2019 standards. Likewise, any providers who were credentialed and in good standing that would not meet the new 2020 standards have been allowed to remain credentialed and granted grandfathered status. Any grandfathered provider who allows their credentialing to lapse and is forced to re-apply as a new applicant will be subject to the new 2020 standards.

The full Credentialing Plans, which are now identical to each other, are posted online under the provider section of both the Avera Health Plans and DAKOTACARE websites. If you have any questions, please reach out to our Provider Relations team and they will be happy to help you.

Rocky Mountain Holdings Agreement

Rocky Mountain Holdings Agreement

Avera Health Plans is pleased to announce an agreement with Rocky Mountain Holdings, LLC, the local operator of the Black Hills Life Flight air ambulance service based out of Rapid City, S.D.

Under the agreement, which was effective Feb. 1, Rocky Mountain Holdings will accept the amount allowed by Avera Health Plans as full settlement of their charges. The arrangement eliminates member exposure to balance billing – the difference between the provider’s normal billed charges and the amount allowed by the health plan – and protects them from thousands of dollars in unplanned financial liability should they need air ambulance transportation.

The agreement includes all of the air ambulance services operated by Rocky Mountain Holdings, which is one of the largest air ambulance providers operating in the United States with 38 distinct air ambulance operations. For a full listing of the air ambulances operated under Rocky Mountain Holdings, please visit their website at

Avera Health Plans now has formal agreements with Rocky Mountain Holdings, Avera Careflight and Medical Air Rescue Company to accept our allowed amount. The agreement with all three air ambulance providers includes Avera Health Plans as well as DAKOTACARE and DAKOTACARE Administrative Services.

Outpatient PT and OT Furnished by PTAs/OTAs

Outpatient PT and OT Furnished by PTAs/OTAs

In the 2019 Physician Fee Schedule (PFS) final rule, the Centers for Medicare & Medicaid Services (CMS) finalized two new payment modifiers to identify services furnished in whole or in part by physical therapy assistants (PTAs) and occupational therapy assistants (OTAs).

The modifiers are voluntary for services occurring between Jan. 1, 2019, and Dec. 31, 2019. For services occurring as of Jan. 1, 2020, and after the modifiers are required.

  • Modifier CQ – Outpatient physical therapy services furnished in whole or in part by a PTA
  • Modifier CO – Outpatient occupational therapy services furnished in whole or in part by an OTA

The Avera Insurance Division follow CMS guidance as it pertains to these two modifiers. Beginning in calendar year 2022, reimbursement for services with these modifiers will be reduced by 15%.

Annual Provider Directory Accuracy Survey Released

Annual Provider Directory Accuracy Survey Released

Maintaining accurate provider directory data is important to Avera Health Plans. Under our National Committee on Quality Assurance (NCQA) accreditation, we take proactive steps on an annual basis to assess our physician directory accuracy focusing on the following areas:

  • Accuracy of office locations and phone numbers
  • Accuracy of hospital affiliations
  • Accuracy of accepting new patients
  • Awareness of physician office staff of physician’s participation in the organization’s networks

We recently sent emails to the credentialing contacts on record for a random sample of approximately 500 physicians from our provider directory. This email included a link to a Survey Monkey tool, providing the recipient an opportunity to review the accuracy of the information included.

It’s possible the credentialing contact on record for your practice received more than one invitation to participate as each email is specific to a particular physician listing being sampled and checked. The results of the survey are compiled so that we can identify and act on opportunities for improvement. Thank you for your time and participation in this process as it allows us to continuously improve the accuracy of our provider directory.

As a reminder, you can submit changes to us anytime by using our online Provider Change Request form. Reported changes are applied to the directory details for Avera Health Plans as well as DAKOTACARE and DAKOTACARE Administrative Services.

Our Provider Relations Specialists are here to assist you with any questions and can be reached directly by phone or email:

Provider Relations Territory Map

Provider Relations Territory Map

Our Provider Relations team is here to help. Questions on who to contact? See our territory map.