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ProviderView Quarterly eNewsletter

June 2019

Preauthorization Changes for DAKOTACARE and DAS Members

Preauthorization Changes for DAKOTACARE and DAS Members

As part of the ongoing integration initiatives within the Avera Insurance Division, we are making changes to the utilization management requirements for preauthorization of services for DAKOTACARE and DAS members. Please share this information with the staff in your office currently responsible for the preauthorization processes.

As of June 1, 2019, DAKOTACARE will no longer allow phone calls for notification of a member’s admission, continued stays, or requests for services. We will require use of the DAKOTACARE Preauthorization form, which reduces the potential for error when taking information verbally or listening to voice messages. This also creates a more uniform and efficient process for our providers and staff. The form mirrors those used for preauthorization for Avera Health Plans members and can be found on the DAKOTACARE website.

Preauthorization/Denial Letter Format

Preauthorization/Denial Letter Format

You may have noticed the new format of the authorization and denial letters. This format is due to the implementation of a new utilization management system called Conifer. The information contained within the letters is similar but may look a bit different.

Neonatal Intensive Care Unit Preauthorizations

Neonatal Intensive Care Unit Preauthorizations

In the past, babies in the neonatal intensive care unit (NICU) have been authorized for up to 21 days at the time of the initial admission.

Going forward, admissions to the NICU who are on the notification report will be given five days, which is consistent with all other admits. After the initial five-day stay and upon notification of the continued stay, additional days will be authorized based upon the baby’s gestational age and condition.

Testosterone Injections and Other Self-Injectable Drugs

Testosterone Injections and Other Self-Injectable Drugs

The Avera Insurance Division Pharmacy and Therapeutics Committee maintain a list of self-injectable drugs that may be covered under a pharmacy benefit. Please note that this list is subject to change and is not a guarantee of coverage. View the current list of self-injectable drugs.

As a reminder, testosterone injections [J1071: injection, testosterone cypionate, 1mg; J3121: injection, testosterone enanthate, 1mg] are on the self-injectable list. If testosterone is administered in a physician office setting, the drug and administration charge will both be denied* as a provider liability. These injections can be self-administered and will be processed under a pharmacy benefit only. Practices that have been billing for these injections in their office should write the member a prescription, which can be used to pick up the testosterone injections from the pharmacy.

* Exceptions include members with cognitive impairment, blindness, paralysis or other mental/physical disability that would prohibit self-administration. In these cases, preauthorization is required prior to administration.

Take Advantage of These Provider Manual Features

Take Advantage of These Provider Manual Features

Avera Health Plans includes important information to review in the Provider Manual, which is available on the Avera Health Plans website:

  • How to refer patients to complex case management services
  • How to obtain utilization management criteria
  • Affirmative statement about incentives
  • Practitioner rights in the credentialing process
  • Member rights and responsibilities

Dental Predeterminations

Dental Predeterminations

If you are submitting a dental predetermination form, please attach clinical information and films to expedite this process.

Updated Medical Policies

Updated Medical Policies

  • Applied Behavioral Analysis for Autism Spectrum Disorder (previously Pervasive Developmental Disorders (PDD) Diagnosis and Treatment)
  • Continuous Glucose Monitoring (CGM) System
  • Experimental, Investigational and Unproven
  • IntraOperative Electron Radiation Therapy (IOeRT) for the Treatment of Breast Cancer
  • Oncotype Dx Assay for Breast Cancer
  • Radiofrequency Facet Denervation
  • Salivary Hormone Tests
  • Urinary Incontinence Treatments

Access to these policies can be obtained by going to either the Avera Health Plans or DAKOTACARE website or through a request to Customer Service or Provider Relations.