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ProviderView Quarterly eNewsletter

December 2018

Avera Health Plans and DAKOTACARE Consolidate Preauthorization, E&I and Preventive Lists for 2019

Avera Health Plans and DAKOTACARE Consolidate Preauthorization, E&I and Preventive Lists for 2019

To better meet the needs of our members and the providers who serve them, Avera Health Plans and DAKOTACARE are taking steps to build a program that is both consistent and efficient.

To reach this goal, we are excited to announce that as of Jan. 1, 2019, the following lists were consolidated for Avera Health Plans and DAKOTACARE for fully insured groups, including the Avera Health Employee Health Plan:

  • Preauthorization list – Note that coverage rules vary by plan; therefore something may be listed on the preauthorization list that may not be covered on the plan.
  • Experimental and investigational list (E&I) – For all plans, E&I products and services are not covered.
  • Products and services list – For compliance with the Affordable Care Act.

To accomplish this consolidation, we took a close look at each of these lists from Avera Health Plans and DAKOTACARE. These were reviewed for clinical appropriateness based on utilization versus risk and evidence-based guidelines.

To find these consolidated lists for 2019, visit or

Avera Health Plans Quality Improvement Program

Avera Health Plans Quality Improvement Program

Occasionally, we receive questions about what actions Avera Health Plans takes to ensure quality. The Avera Health Plans Quality Improvement Program is designed to objectively and systematically monitor and evaluate the quality, appropriateness and effectiveness of care.

The current goals and objectives include:

  • Maintaining a Quality Improvement structure and process that supports continuous improvement including measurement; analysis; intervention; and re-measurement for issues involving patient safety, quality of care, and outcomes
  • Defining clinical quality and building organizational capabilities to support the achievement thereof
  • Systematically monitoring and evaluating key indicators and measures to detect trends and identify opportunities to improve quality of care and service to members
  • Identifying, prioritizing and developing interventions that target opportunities for improvement, identifying variance from performance goals and benchmarks, developing and testing improvement and evaluation plans, and regularly re-evaluating quality improvement efforts
  • Developing data-driven disease and complete case management strategies to improve practitioner and member compliance with clinical and/or behavioral health guidelines and standards
  • Ensuring a system of continuous quality improvement communication that is timely and reports through appropriate channels to appropriate individuals
  • Monitoring ongoing compliance with applicable accreditation and regulatory standards
  • Enhancing relationships with physicians by engaging in collaborative process improvements and supporting them to improve clinical quality and to better manage the care of targeted members
  • Serving and improving clinical outcomes for members with complex health needs, disabilities, and severe and persistent mental illness through our complete case management program; monitoring and improving access to care; and monitoring and improving continuity and coordination of care across multiple settings
  • Validating quality of care trends and communicating trends to Avera Service Lines
  • Providing education to members and network behavioral health care practitioners regarding appointment availability standards
  • Implementing a population health program with data analytics tools
  • Integrating adverse events reporting with Avera Health System initiatives

Dry Needling

Dry Needling

A therapy used to treat muscular tension and spasms with the goal being reduced pain and increased flexibility is gaining new traction. This therapy, termed dry needling involves insertion of thin needles into pressure points. The procedure can be done as a standalone treatment, however, is often used in conjunction with other treatment modalities. As of July 1, 2018, South Dakota allows physical therapists to perform dry needling if they have the proper knowledge and training.

Avera Health Plans was asked to make a determination on coverage. Published medical literature was reviewed and resources such as Hayes accessed prior to rendering a decision. The material and information indicate at the current time efficacy and effectiveness has not yet been established resulting in a designation of experimental and investigational. Keep in mind, this is not unusual for newer procedures and treatment and the designation may change in the future as more information and studies becomes available.

2018 Physician Directory Accuracy Report

2018 Physician Directory Accuracy Report

It is important for Avera Health Plans to ensure that the information in the physician directory is accurate. This provides our members with accurate information on in-network physicians to avoid barriers to access. Avera Health Plans validates the data that appears in the provider directory on an ongoing basis. 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 September 2018, Avera Health Plans submitted 502 queries to randomly selected physicians with 327 responses received. Results from the survey showed:

2018 physician directory accuracy report

Three of the five categories met or were right at the set goal. One of the areas surveyed that didn’t meet the set goal was ‘Accepting New Patients,’ which was 66.9 percent accurate. This could be attributed to a modification in the programming between IT and the vendor that was taking place at the time of this survey. ‘Hospital Affiliation’ was also slightly below the set goal. Providers or their credentialing contact need to validate this information during re-credentialing so updates or changes can be added to the directory.

For more information, contact Chuck Hanisch, Accreditation Coordinator, Quality, at or 605-504-0052.

Correct Billing of Units

Correct Billing of Units

When billing services are provided to patients, providers must distinguish between timed (constant attendance) codes and untimed (service-based) codes. For many untimed services provided, you can bill one unit, unless the code description/definition clearly indicates additional units applicable for size, weight or number of services provided.

When submitting a claim for payment to Avera Health Plans, it is important to bill the correct amount of units. In many cases, a procedure or supply has a specified number of units as part of the definition of the code. To determine how to report the units within the guidelines for the code, follow guidelines as defined in the code definitions and maximum number of units rules. Here are some important considerations or tips when billing units:

  • For procedures provided multiple times on a single date of service, enter the procedure once and use the unit’s field to indicate the number of times the service was provided.
  • Pay attention to the definition, which may include references to time, size, weight or days to accurately calculate the number of units.
  • Be aware of Medicare Medically Unlikely Edits (MUE) CMS guidelines.
  • The rendered service must meet the definition of a minimum of one unit in order to be reported, partial units are not allowed.
  • Ensure that the number of units/days and the date of service range are not contradictory.
  • Ensure that the number of units/days and the quantity indicated in the procedure codes description are not contradictory.

If reporting service units for CPT or HCPCs codes where the procedure is not defined by a specific timeframe (untimed CPT or HCPCs), the provider enters “1” in the field labeled units. For untimed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCs code definition. Often the definition indicates the service is once per day, per muscle group or anatomical body region, diagnostic test or sample, or lesion. If billing more than one unit on a code, be sure the definition of the code allows for multiple units.

Avera Health Plans follows The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of time based physical medicine CPT codes to report. Avera Health Plans refers to this as the "Rule of Eight."

According to the "Rule of Eight," the provider must spend more than one-half (eight minutes or more) of a given 15-minute time component with the patient performing treatment in order to report that unit of service. A single 15-minute unit of a timed service is equal or greater than eight minutes but less than 23 minutes. If the service is performed for less than eight minutes, the unit should not be reported.

The following are guidelines for billing multiple units of timed services:

  • Two units are greater than or equal to 23 minutes but less than 38 minutes
  • Three units are greater than or equal to 38 minutes but less than 53 minutes
  • Four units are greater than or equal to 53 minutes but less than 68 minutes

Avera Health Plans also follows this CMS guideline: "If any 15 minute timed service that is performed for seven minutes or less than seven minutes on the same day as another 15 minute timed service that was also performed for seven minutes or less and the total time of the two is eight minutes or greater than eight minutes, then bill one unit for the service performed for the most minutes. The same logic is applied when three or more different services are provided for seven minutes or less than seven minutes.¹"
-¹Medicare Claims Processing Manual, Chapter 5 – Part B Outpatient Rehabilitation and CORF/OPT Services (Rev. 2868, 02-06-14), pg. 38

Universal Contracting

Universal Contracting

Thank you for your responsiveness to Avera Health Plans and DAKOTACARE Universal Contracting Initiative.

Avera Health Plans and DAKOTACARE recently concluded work on a new initiative to contract with non-Avera-employed physicians and providers for both plans under a single, universal contract.

Affected providers received letters of termination for their provider agreements with Avera Health Plans and DAKOTACARE effective Dec. 31, 2018. Included in the notification was their new contract, which will go into effect Jan. 1, 2019. The Avera Insurance Division is pleased to announce that 97 percent of the provider agreements were returned and are being processed with an executed copy submitted back to the providers’ offices. As we near the end of 2018, we want to reflect and say thank you to all those who worked with our Provider Relations staff to complete and return the required contract documents. We feel strongly that the Universal Agreement will benefit you by providing unified transactional experiences through areas such as credentialing and reimbursement.

For those offices that chose not to return the provider agreement, of the remaining few agreements, we will begin the process of notifying members of your desire to no longer participate with Avera Health Plans or DAKOTACARE where necessary.

Our goals with this initiative include simplifying administrative functions, creating an environment for partnership to meet member and patient needs, and keeping insurance risk with the health plan while we innovate with providers who are interested in participating in new payment models that reward value and quality. There will be exciting opportunities and alignment between many policies and procedures as we move forward working with the providers in our region.

Although there is minimal network disruption through this initiative, we ask that you continue to utilize resources like our online provider directory and Customer Service Center (1-888-322-2115) to ensure referrals are to other in-network providers when necessary.

Avera Health Plans Clinical Review Affirmative Statement About Incentives

Avera Health Plans Clinical Review Affirmative Statement About Incentives

Clinical Review decision-making is based only on appropriateness of care and service and existence of coverage. Avera Health Plans does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for clinical review decision-makers do not encourage decisions that result in underutilization.

Preauthorization Changes for Advanced Imaging Services Effective Jan. 1, 2019

Preauthorization Changes for Advanced Imaging Services Effective Jan. 1, 2019

As part of the ongoing integration initiatives within the Avera Insurance Division to create a more uniform and efficient process for our providers, we will be making significant changes to the clinical review requirements for advanced outpatient imaging services for both Avera Health Plans and DAKOTACARE. Please make sure you share this information with the staff in your office currently responsible for the preauthorization processes.

Today, Avera Health Plans utilizes eviCore as a third party vendor to manage the preauthorization of a list of advanced outpatient imaging services comprised of approximately 120 CPT codes in the categories of MRI, MRA, CT, CTA and PET imaging technologies. While this requirement and the relationship with eviCore will remain in place for our third-party administration services for John Morrell (Smithfield Foods), it will change to a notification only process that will be handled internally for all other lines of business. The list of codes that will require notification is focused on a sub-set of about 50 codes from the current eviCore list and has been posted online. Specifically:

Avera Health Plans Fully-Insured Small Group, Large Group and Individual Plans:

  • Identified by group numbers on the ID cards beginning with IA, NE, SD, SDMP and SIND.
  • Continue as normal using eviCore for all codes on the current eviCore list for all imaging preauthorizations requested through Dec. 31 2018, even if the planned date of service will occur in 2019.
  • Beginning for all requests Jan. 1, 2019, and later, the process will change to notification only for the shorter list of codes and be handled by using the Radiology Notification Form, which have both been posted online.

Avera Health Plans Third-Party Administration of Benefits for the Avera Health Employee Health Plan:

  • Identified by group numbers on the ID cards beginning with AAH or AH.
  • Continue as normal using eviCore for all codes on the current eviCore list for all imaging preauthorizations requested through Dec. 31 2018, even if the planned date of service will occur in 2019.
  • Beginning for all requests Jan. 1, 2019, and later, the process will change to notification only for the shorter list of codes and be handled by using the Radiology Notification Form, which has been posted online.

Avera Health Plans Third-Party Administration of Benefits for John Morrell (Smithfield Foods):

  • Identified by group numbers on the ID cards beginning with JMC, JMJ, JMM, JMO, JMS, JMZ or PCG.
  • No changes in 2019. Continue to use the eviCore list of codes with eviCore managing the preauthorization as normal.
Answers to Frequently Asked Questions:

What is the difference between the new radiology notification versus the preauthorization process?
Notification does not require any clinical questions to be answered to make a determination. The notification process will be handled directly by our local staff instead of through eviCore.

How will the notification process be handled?
The radiology notification process will be handled by fax. While we are exploring an option for completing the notifications online, that option will not be initially available.

Does the notification need to be completed on a pre-service basis?
Yes, every effort should be made to fax the Radiology Notification Form to us pre-service, but we will accept the notifications up to 15 business days after the service date.

What happens if I fail to submit the notification on one of the required codes?
The notification process will be treated the same way the existing preauthorization process is handled under your provider agreement. Failure to perform the required notification will result in denial of the service as a full provider liability.

What information will be required on the Radiology Notification Form and where can I find it?
The form is currently available on the Avera Health Plans website. From the main page follow these hyperlinks: For Providers; Preauthorizations; Preauthorization/Notification Forms and then it’s found under the Radiology Notification Form link. The website is undergoing re-design for improved ease of navigation so the location may change as these improvements are implemented. If you have any trouble finding the form, our Service Center and the Provider Relations Team can assist you.

Where can I find the list of the 50 advanced imaging codes subject to the new notification process?
The codes have also been posted online and can be accessed by typing in a group number from the preauthorization page. For example, if you type in SDMP11, it will take you to a page that is currently separated into a 2018 / 2019 configuration. On the right side under, 2019 Medical Preauthorization/Notification Requirements, there is a link: List of Services Requiring preauthorization for 2019 Procedures. Once the PDF behind that link has been opened, the appropriate radiology codes are denoted under the left-most Requirement column as a Notification.

How will I know that my faxed Radiology Notification Form was received and what kind of a confirmation should I expect?
The notification forms will generate a traditional authorization number (even though it’s only a notification) that will be faxed back to the requestor. This will serve as your confirmation that the notification was received and entered into our claims system. It is not necessary to report the authorization number to us on any claims filed for the services.

Who can initiate the notification process?
Because there is no need to have detailed clinical information about the member to perform the radiology notification, the notification can be completed by either the ordering provider or by the rendering site of service unlike the preauthorization process, which requires the ordering provider’s office to complete the preauthorization request.

Are there sites of service that are excluded from the notification requirements?
Yes, the notification process is not required in an inpatient setting or for imaging services initiated as an encounter to the emergency room of a hospital.

Why will John Morrell continue with the full advanced outpatient imaging requirements through eviCore rather than moving to the new notification process?
As a self-funded employer group, Avera Health Plans administers benefits to the specifications of the employer. The current specifications for John Morrell include preauthorization of these imaging services as a component of their overall clinical review procedures.

What about DAKOTACARE? Does this new notification process affect DAKOTACARE Administrative Services clients?
The new notification requirement applies to both DAKOTACARE HMO and DAKOTACARE Administrative Service (DAS) clients who receive advanced outpatient imaging services.

Why is this change being implemented and if there is no clinical evaluation resulting in an approval / denial pathway as in traditional preauthorization why have the notification process at all?
As part of our ongoing integration for both DAKOTACARE and Avera Health Plans, we recognized that in order to standardize our transactional processes we either had to add eviCore requirements for DAKOTACARE or develop an alternate solution. DAKOTACARE had prior experience with the Radiology Notification Process that worked well for them. The notification process still affords us the opportunity to track and monitor utilization rates real time rather than through a retrospective claims analysis. If unusual utilization patterns begin to emerge, we will work collaboratively with those specific providers in an effort to ensure that nationally accepted standards of care for imaging utilization are being followed in the interests of providing high quality, cost affordable care that minimizes unnecessary radiation exposure. As performance based payment models continue to evolve, opportunities to align incentives with providers, including utilization metrics will provide better pathways than traditional preauthorization.

We recognize that this change is taking place rapidly and there will be additional questions. Our Service Center and Provider Relations staff stands ready to offer assistance.