ProviderView Masthead

ProviderView Quarterly eNewsletter

March 2017


Preauthorization Lists Updated Online

As part of our annual review and process, the lists of codes requiring preauthorization have been updated online for 2017.

All of the necessary references and resources for managing the preauthorization process can be accessed online at in the Providers section. Under Patient Health Management, click the Preauthorization link. By entering the group number off the ID card, you will be taken to a page that includes all of the preauthorization resources including complete lists for medical, pharmacy and imaging along with any necessary forms and contact information.


Experimental Services

Experimental/Investigational Services

Every year on Jan. 1, CPT and HCPCS codes are updated (new, revised and deleted) by the American Medical Association (AMA). Avera Health Plans implements numerous processes to be prepared for this annual code update and to ensure timely payment of claims. Part of the review process includes assessment of new technologies or application of existing technologies for a new procedure or service to determine if it is experimental or investigational.

The Investigational, Experimental and Unproven medical policy outlines, in detail, the process for reviewing those technologies. If a service is determined to be experimental or investigational by Avera Health Plans’ chief medical officer and approved as such by the Quality Improvement and Utilization Committee, the service will be denied as provider liability consistent with the terms and conditions of the provider agreement with a message that indicates “Experimental/Investigational is not covered.”

Participating providers who wish to offer these services and preserve their right to bill our members can do so by executing a Patient Waiver Form as described in Section 4.7 of the Avera Health Plans Provider Manual. If your office needs assistance in navigating this process, our Provider Relations Team is happy to assist you.

While individual benefit determinations made on claims that have been denied as experimental or investigational are not eligible for review through the request for reconsideration process, we do welcome new clinical evidence that becomes available related to established policy positions for prospective consideration.

To locate the Investigational, Experimental and Unproven medical policy and the list of codes:

  1. Please log in our website
  2. Click on the “Policies” tab located on the navigation bar
  3. Click on the link titled “Click here to view medical policies.”


2017 HEDIS Medical Record Abstraction Activities

The Healthcare Effectiveness Data and Information Set® (HEDIS) is a set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA), a nonprofit organization committee to assess, report and improve the quality of care provided by organized delivery systems. These performance measures are used as a tool by health plans to collect data about the quality of care and services they provide to their members. HEDIS results are utilized in quality improvement activities and disease management programs. Public purchasers, regulators and consumers also use HEDIS results as a way to compare the performance of health plans. Avera Health Plans will be in the process of gathering information for HEDIS reporting February through May.
In order to complete HEDIS reporting for 2017, Avera Health Plans must gather medical record information for select HEDIS measures including:

  • Adult BMI assessment
  • Weight assessment and counseling for nutrition and physical activity for children/adolescents
  • Childhood and adolescent immunization status and HPV
  • Colorectal cancer screening including colonoscopy, flexible sigmoidoscopy and fecal immunochemical testing
  • Controlling high blood pressure
  • Comprehensive diabetes care including HbA1c, attention for nephropathy and retinal eye examination
  • Prenatal and postpartum care

Medical record requests will be sent to your office beginning in February and will include the member’s name, date of birth, member identification number, practitioner name and the time frame for which records are needed. We request the records to be copied and mailed, faxed or uploaded according to the directions on the request form.

If the volume of records requested from your clinic is too large, or you do not have adequate staff to complete this task, please email or call 605-322-3706.


Provider Scorecard

For the last several months, Avera Health Plans and Avera Medical Group have been working collaboratively to develop a Provider Scorecard. The Scorecard will tie in clinical data straight from the EMR to the attributed members, and allow physicians a quick snapshot of members with a Risk Adjustment or HEDIS gap. Provider Scorecards will be delivered quarterly to clinic staff to allow providers an opportunity to reach out to their patients and encourage them to come into the clinic for an office visit to address gaps in care, including condition management. For more information on Provider Scorecards, please contact Sara Hansen, Avera Health Plans Risk Adjustment Coordinator, at 605-322-2329 or


CAHPS Survey Forthcoming

  • CAHPS stands for Consumer Assessment of Healthcare Providers and Systems
  • CAHPS is a survey that goes out to Avera Health Plans members every February
  • The CAHPS survey asks our members/your patients how they rate specific aspects of care, providers and health plans.
  • CAHPS is a different survey than the HCAHPS, but the concept is the same.
  • Some CAHPS questions include:

Getting Needed Care - How often it was easy for members to

Get appointments with PCP/ specialists
Get the care, tests or treatment they needed through their health plan

Getting Care Quickly - How often members

Got care as soon as they needed when they were sick or injured
Got an appointment when they weren’t sick or injured

How Well Doctors Communicate - How often their personal doctor

Explained things in a way that was easy for them to understand
Listened carefully to them
Showed respect for what they had to say
Spent enough time with them

  • CAHPS survey results will be distributed to providers this summer


Welcome Micah Linn

Avera Health Plans would like to welcome Micah Linn to the Provider Relations team. Micah is a Provider Relations Specialist, and he joined us from previous employment at Wells Fargo. He will be working with our network of providers to make sure they are updated on policy changes and all things Avera Health Plans.

Originally from Norwalk, Calif., Micah attended Northwestern College in Orange City, Iowa. He also has a graduate degree from the University of Phoenix. Micah looks forward to working in the health care field and learning the ins and outs of the insurance world, as well as working with our Provider Relations team. You can reach him at 605-322-3643 or at Welcome, Micah!