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ProviderView Quarterly eNewsletter

March 2018

Preauthorization Changes

Preauthorization Changes

Preauthorization requirements are reviewed on a continual basis. Some can be changed but others are under the control of the employer or payor. Starting Jan. 1, 2018, the following codes will not require preauthorization for the fully insured employer group or individual plan benefits and Avera Health employee plan benefits. The expectation is these procedures will continue to meet medical necessity and audits can be conducted at any time to ensure compliance.

CPT codes - Neuroablation: 64633 – 64636
CPT codes - Facet: 64490 – 64495
CPT codes - Epidural: 0228T – 0231T, 62320 – 62323, 64479, 64480, 64483, 64484
CPT codes - SI Joint: 27096

Preauthorization requirements are reviewed and updated on a regular basis by our Medical Management care team at Avera Health Plans. We encourage you to verify if preauthorization is needed before the procedure is scheduled. Visit Avera Health Plans website for the latest updates.

Stool DNA Added to Our Preventive Services List

Stool DNA Added to Our Preventive Services List

Avera Health Plans added the following colorectal cancer screening test to our medically necessary preventive services list for average-risk members aged 50 years and older when recommended by a health care provider:

  • Stool DNA (i.e., FIT-DNA, Cologuard) considered medically necessary every three years for person at average risk

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
  • Pharmaceutical restrictions and preferences
  • Practitioner rights in the credentialing process
  • Member rights and responsibilities

Home Sleep Study Criteria Developed

Home Sleep Study Criteria Developed

A medical coverage policy for home sleep studies has been developed and outlines the criteria for medical necessity as well as coverage determination. Access the details of the Home Sleep Study, located with our policies online, by logging into the provider portal Avera Health Plans.com.

Accuracy Goals Met in Provider Directory Validation Project

Accuracy Goals Met in Provider Directory Validation Project

As an NCQA accredited health plan, Avera Health Plans reviews and validates the data that appears in our online provider directories on an ongoing basis. Information including address, phone numbers and hospital affiliations is analyzed annually to identify opportunities for improvement through random selection of our more than 10,000 providers. We reached out to approximately 1/3 of the provider offices to verify that information we publish matches the expectations of providers’ offices with a goal of more than 90 percent accuracy on the published data. We are happy to report that the survey responses indicate that office location, phone number, accepting new patients and awareness of physician participation by office staff met our accuracy goals for primary care and specialists providers. We’ll continue to update the provider directories as new information is submitted. It is measured on an annual basis.

Avera Health Plans Announces New Hires

Avera Health Plans Announces New Hires

Staying on top of quality, utilization management and risk adjustment are of vital importance to Avera Health Plans. New hires are now on board to help focus our efforts.

Renee Schroeder, MD, joined Avera Health Plans as the Medical Director of Quality and Utilization Management. She will help address all the operational aspects of risk adjustment, quality, pharmacy and population health.

Corey Weeg has a new role as Director of Risk Adjustment. He previously served as a member of the Avera Health Plans finance team. Corey is working to maximize risk adjustment revenue opportunities and minimize health plan risk. He will also develop strategy with provider groups to deliver programming, education and training to ensure that strategies for member outreach are aligned with quality and medical management.

Patti Brooks joined Avera Health Plans as the Director of Quality and Accreditation. She will oversee the NCQA coordination efforts, HEDIS measure coordination, quality of care reviews, and appeals and grievance processes. Within the Quality Department, Chuck Hanisch has been hired as the new NCQA Coordinator and Stacie Bleeker as the HEDIS Coordinator.

Two Record Review Initiatives Underway

Two Record Review Initiatives Underway

By Sara Hansen, Manager of Risk Adjustment

Information is key to understanding a variety of concepts. At Avera Health Plans, a great deal of information is required to satisfy regulatory requirements. During the late winter and early spring months, two major initiatives require medical record review for reporting.

HEDIS
Healthcare Effectiveness Data and Information Sets (HEDIS) is a set of standardized performance measures designed to ensure that the public has the information it needs to compare organizations’ performance, and encourages accountability and quality improvement in health care. As an issuer accredited by National Committee for Quality Assurance (NCQA), Avera Health Plans is required to submit data directly from medical records to provide support for quality metrics and initiatives.

RISK ADJUSTMENT
Risk adjustment is a premium stabilization program developed as part of the Affordable Care Act of 2014, designed to support guarantee issue. Because issuers (such as Avera Health Plans) are prohibited by law to rate premiums based on health status, risk adjustment allows for health status comparison between issuers following each benefit year. As such, Avera Health Plans will be requesting records to ensure that the health conditions reported to CMS are documented within the medical record, as well as report any additional conditions found within the medical record not yet reported to CMS.

With the two initiatives running concurrently, Avera Health Plans will be working diligently to minimize provider disruption. Please report any issues regarding requests to Avera Health Plans’ Provider Relations.

If you have any concerns about Avera Health Plans’ record retrieval process, please contact Sara Hansen, Manager of Risk Adjustment, at sara.hansen@avera.org or 605-322-2329.

Improving Access with Hy-Vee Healthy You Mobile

Improving Access With Hy-Vee Healthy You Mobile

By Sara Hansen, Manager of Risk Adjustment

Convenience has become a major requirement for almost anything busy Americans consider purchasing. But how often do people think of health care as convenient? At Avera Health Plans, improving access to care is as important to us as the quality of care itself. One way we aim to improve access is by bringing the care to our members – on wheels!

Through a partnership with Hy-Vee, Avera Health Plans is providing annual wellness visits on the Hy-Vee Healthy You Mobile, powered by Avera. The bus is a fully equipped mobile exam unit, with private exam rooms and a comfortable waiting area, that allows members to receive many services typically available in a clinic (body mass index, cholesterol, blood sugar, blood pressure, and preventive screening counseling) in an efficient, private and convenient manner.*

To learn more about the Hy-Vee Healthy You Mobile, or to inquire about providing exams on the mobile unit, please contact Sara Hansen, Manager of Risk Adjustment, at sara.hansen@avera.org or 605-322-2329.

*Members qualify for one annual wellness visit (preventive exam) every 12 months.

Streamlined Radiology Preauthorization

Streamlined Radiology Preauthorization to Save Providers Time in Scheduling Peer-to-Peer Conversations

eviCore, the vendor that provides radiology utilization management services for Avera Health Plans, recently rolled out a new, streamlined process for requesting peer-to-peer conversations, designed to save providers time and be more convenient for the ordering provider’s schedule .

When a radiology preauthorization has been referred to medical review, and the provider has determined that they wish to have a peer-to-peer conversation, the provider now has a choice:

  1. Schedule a peer-to-peer review. This prevents time on hold waiting for a connection with the reviewing peer.
  2. If the need is truly urgent, choose to wait on hold for a warm transfer – both the eviCore representative and the requesting provider (or clinic team member) will wait for a connection to a reviewing peer.

The option to schedule a time reduces hold time and removes less urgent requests from the queue.
To learn more, view Online Peer-to-Peer scheduling.