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ProviderView Quarterly eNewsletter

July 2017

Provider Education: Risk Adjustment

Provider Education: Risk Adjustment

It is often said that humans are lifelong learners. At Avera Health Plans, learning takes place every day. We are making an effort to share opportunities for growth and learning with our providers.

Risk adjustment is a premium stabilization program that was established through the Affordable Care Act (ACA), and is also utilized in the Medicare Advantage space. For the ACA population, health plans evaluate their population through diagnoses captured on claims and compare to other health plans within the state. The plan with the highest “sickness” score receives a transfer payment from the other plan to share the risk of the population in the absence of rating health status upon enrollment. Over the next several months, Avera Health Plans’ risk adjustment staff will be visiting a variety of clinics throughout the region to discuss risk adjustment in greater detail and explain how it can benefit our providers as well as our members to be aware of the program.

If you have questions about risk adjustment or provider education, please contact Sara Hansen, Manager of Risk Adjustment, at sara.hansen@avera.org or 605-274-3163.

Reporting Accurate Type of Bill (TOB) Codes Important for UB-04 Submitters

Reporting Accurate Type of Bill (TOB) Codes Important for UB-04 Submitters

As a Qualified Health Plan (QHP) selling insurance products under the Affordable Care Act (ACA), Avera Health Plans annually reports de-identified claims data through an External Data Gathering Environment, referred to as the EDGE server.

The reporting of this de-identified claims data is a critical element of ACA’s risk adjustment program, which is intended to reinforce market rules that prohibit risk selection by insurers. Risk adjustment does this by transferring funds from plans with lower-risk enrollees to plans with higher-risk enrollees. Risk adjustment helps to stabilize premiums and the costs of tax credit subsidies to the federal government.

Software designed by the Centers for Medicare & Medicaid Services (CMS) is used to assess the claims data stored in the EDGE server environment to establish our risk score. This software includes very specific editing rules on the claims data. Any data that does not pass these edits is excluded from a plan’s risk score calculation. Therefore, it is very important that our claims data passes these edits to ensure we receive all of the credit due in the risk scoring process.

One of the more common errors seen with our EDGE server data is data rejection due to inaccurate reporting of type of bill codes on UB-04 claims. For example, we may have a claim reported as a bill type 112 – hospital, inpatient, interim first claim but not have a corresponding claim billed as 114 – hospital, inpatient, interim last claim. Or we may have a claim with the third digit of the type of bill code reported as a 7 (replacement of a prior claim) but yet not have a prior claim in our data.

In both of these examples, the data is rejected by the CMS software and therefore excluded from our risk adjustment scoring. Because of the importance of the annual risk scoring process to our overall financial performance, Avera Health Plans has taken steps to tighten up our adjudication rules related to accurate reporting of type of bill codes on UB-04 submissions. You may see rejections or denials if it is determined that there are errors in the way you report the type of bill code on your submissions. If you are receiving rejections or denials related to your UB-04 claims and have questions, our Provider Relations team is happy to provide assistance.

DAKOTACARE and Avera Health Plans Create One Comprehensive Health Services and Medical Management Program

DAKOTACARE and Avera Health Plans Create One Comprehensive Health Services and Medical Management Program

Avera Health Plans and DAKOTACARE have combined their teams into one comprehensive health services program spanning both organizations. The combined program will manage preauthorization, quality reporting, pharmacy services, and population health, including wellness and disease management programs to help all members live healthier lives.

Providers will begin to see one clear path of connection from their patient members to disease management programs for conditions like diabetes, depression, asthma, COPD and heart disease.

Contact information has not changed. Providers can continue to use the same phone, fax and emails they have used in the past to request preauthorizations.

DAKOTACARE
Phone: 1-800-658-5508
Fax: 605-274-3279
Email:customer-service@dakotacare.com
dakotacare.com

Avera Health Plans
Phone: 1-888-605-1331
Fax: 1-800-269-8561
Email: healthservices@averahealthplans.com
AveraHealthPlans.com

Reminder: 2017 Fee Schedule Updates

Reminder: 2017 Fee Schedule Updates

As a reminder, Avera Health Plans updates many of our provider fee schedules by July 1 each year to correspond with the annual updates performed by CMS to the Relative Value Units (RVU) and Medicare rates. While new codes are added annually when released, the comprehensive update to the RVU and CMS values are performed each year by July 1 for most of our provider agreements. If you have any questions related to updates that may impact your fee schedule, please contact the Provider Relations team for assistance.

On July 1, we will also do our annual refresh of logins to our portal. If it has been more than 12 months since your last log in, you will need a new registration to log in.

Attention Ophthalmology Offices: Changes in Coding Avastin for Ophthalmic Use Effective June 1, 2017

Attention Ophthalmology Offices: Changes in Coding Avastin for Ophthalmic Use Effective June 1, 2017

Avera Health Plans has historically required the use of code J3590 when administering intravitreal injections of bevacizumab (Avastin) for retinovascular disease indications. We want to inform you of planned changes to our coding standards when Avastin is used in the ophthalmology setting that will align our coding requirements with current CMS standards.

Effective June 1, 2017, we will ask all ophthalmology practices to bill CPT Code J7999 when billing for bevacizumab (Avastin). The standard dose is up to 1.25 mg of bevacizumab per eye, which is 1 billing unit. CPT Code 67028 should also be billed for the injection.

If you have any questions about this change in our coding requirements for the ophthalmic use of Avastin, please contact our Provider Relations team at 605-322-4500.

Give it a Shot: Stay Up-to-Date on Immunizations

Give it a Shot: Stay Up-to-Date on Immunizations

Vaccines give you the power to protect your patients from getting sick. As you know, until we eliminate disease it’s important to keep immunizing patients. The Centers for Disease Control (CDC) and Food and Drug Administration (FDA) take many steps to make sure vaccines are very safe.

Avera Medical Group has launched a new immunization campaign called “Give it a Shot” to urge people to stay up-to-date on vaccinations through adulthood and to serve as a toolkit for providers when speaking with patients.

We have attached several campaign resources that you may find helpful in educating your patients. Our health plan members with dependents will also receive a large magnet with a list of required immunizations for their dependents. Go to Avera.org/shots for more information.