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ProviderView Quarterly eNewsletter

June 2018

Avera Health Plans and DAKOTACARE Introduce Universal Contracting

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

Affected providers recently received letters notifying them that their provider agreements with Avera Health Plans and DAKOTACARE will be terminated effective Dec. 31, 2018. Enclosed was their new contract, which will go into effect Jan. 1, 2019.

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.

To that end, the universal contract demonstrates the following:

Administrative Simplification
  • Transparent allowances for services provided
  • Consistent credentialing, reimbursement and medical management policies in treating members of both plans
  • Contracting based on a clinic or entity level, rather than by individual physician
Creating Opportunities for Future Innovations in Partnering to Meet Consumer Needs by:
  • Focusing on metrics that matter to members and community employers, and are consistent with both professional and accreditation standards
  • Sharing on upside risk opportunities and rewarding providers who are committed to quality, value and affordability
Keeping Insurance Risk with the Insurance Company
  • Eliminating the withhold from paid reimbursement on insurance members services as a mechanism to support the risk-based capital needs of the insurance company

If you have questions, please contact our provider relations team: Mike Dooley at 605-322-4634; Scott Jamison at 605-274-3141; Michael Nour at 605-322-4596; or Micah Linn at 605-322-3643 .

Population Health Project Launched at Avera

Avera recently launched a population health initiative. Avera’s Population Health Project will offer providers enhanced tools and resources, designed to identify which patients can benefit from more proactive intervention, whether that’s encouraging a patient to access wellness visits and screenings to keep them healthy or to wrap them in additional care that will keep their conditions from progressing.

Avera’s Population Health Project focuses on three important groups of patients, where efforts can make the most impact:

  • Avera Health Plans and DAKOTACARE HMO (Health Maintenance Organization) members
  • Those with chronic and/or high cost health care needs
  • Accountable Care Organization patients attributed to
Avera Population health is about delivering the right health care at the right time, to help healthy patients stay healthy and prevent disease and disease progression.

Risk Adjustment Data Validation Audit

by Sara Hansen, Manager of Risk Adjustment

The Patient Protection and Affordable Care Act (ACA) requires issuers of ACA-compliant plans to participate in an audit of health status, enrollment and demographic information of enrollees. In order to comply with government regulations, Avera Health Plans and DAKOTACARE are mandated to participate in the Risk Adjustment Data Validation Audit (RADV) for payment year 2017. In order to adequately support information previously submitted to Health and Human Services (HHS), such as diagnosis codes and health conditions, issuers are required to contract with a vendor to independently audit medical records and enrollment information.

As a reminder, it is a contractual obligation to make medical records available for quality initiaives such as a government mandated audit. Avera Health Plans and DAKOTACARE will make every effort to minimize disruption to your practice through medical records requests by communicating with your staff regarding the best method for obtaining medical records.

If you have any questions regarding medical records requests for audit purposes, please contact Sara Hansen, Manager of Risk Adjustment, at 605-322-2329 or

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.

Annual Portal Refresh

July 1 is our annual portal refresh, to ensure that only active users have access to the Avera Health Plans portal. On July 1, if you have not logged in during the previous 12 months, you will lose access and need a new registration to log in. To maintain your account, be sure to log in prior to July 1.

Pharmacy Tidbits: Small Changes that Make a Big Impact

As a provider, there are instances when a small change in a prescription can make a big difference in coverage and affordability for your patients. Below are some instances where this is the case for Avera Health Plans prescription plan members.


Duexis® contains 800mg of ibuprofen and 26.6mg of famotidine. It is prescribed three times daily for symptomatic relief in rheumatoid arthritis and osteoarthritis. The total cost for a 30 day supply (90 tablets) of Duexis® is approximately $2,450.

A lower cost alternative is ibuprofen 800mg tablets (90 tablets cost less than $10) along with over-the-counter famotidine 20mg (90 tablets cost less than $20).

The member will pay less for the alternative option than what he or she will pay for a Duexis® prescription. Duexis® is not covered on most Avera Health Plans prescription plans.


Diclegis contains doxylamine succinate 10mg and pyridoxine 10mg, in a delayed release tablet, for the treatment of nausea and vomiting related to pregnancy. Initial dosing is two tablets at bedtime, which may be increased up to a maximum of four tablets daily.

A lower cost alternative is to take a half tablet of the over-the-counter doxylamine 25mg and over-the-counter vitamin B6 50mg. The member cost for these two over-the-counter products is less than what the member co-pay would be if the member were to receive Diclegis.

Diclegis is not covered on Avera Health Plans prescription plans nor will formulary exceptions for Diclegis be provided.

Epinephrine Pens

There are several options for epinephrine pens that are available on the market:

  • Two pens of Auvi-Q 0.15mg or 0.3mg exceed $4,800 in costs
  • Two pens of Epi-Pen 0.15mg or 0.3mg costs approximately $600
  • Two pens of epinephrine 0.15mg or 0.3mg costs approximately $300

The lowest cost alternative for a member is the generic product. Auvi-Q does not have a generic alternative available. Avera Health Plans prescription plans do not cover Auvi-Q since there are lower cost alternatives available.

H.P. Acthar® Gel

H.P. Acthar® Gel is an adrenocorticotropic hormone (ACTH) analogue that is FDA-approved for:

  • Treatment of exacerbations of multiple sclerosis in adults
  • Monotherapy for the treatment of infantile spasms in infants and children under 2 years of age.

One vial of H.P. Acthar® Gel (80 units/mL) costs approximately $38,500 resulting in monthly treatment charges exceeding $100,000. Because of the large costs associated with this product, H.P. Acthar® Gel requires preauthorization to ensure proper utilization.

To learn more about pharmacy coverage, visit

Continuous Glucose Monitors

Starting July 1, 2018, for Commercial, Marketplace and employee plans, continuous glucose monitors (CGMs) will require pre-authorization. Codes included in this requirement are:

  • A9277
  • A9278
  • K0554
  • S1030
  • S1031
In contrast, external insulin pumps will not require preauthorization. If in doubt as to what requires a preauthorization, check the look-up tool at