ProviderView Masthead

ProviderView Quarterly eNewsletter

March 2019

Please Take Our Annual Provider Survey

Please Take Our Annual Provider Survey

Each year Avera Health Plans asks providers to offer feedback using a short survey.

Please submit your answers to help us better serve you. All survey participants will be entered in a drawing to win a $100 Visa gift card.

Thank you for your help—we look forward to hearing from you!

Fee Schedule Update

Fee Schedule Update

As a reminder, Avera Health Plans will implement new codes for 2019 with the implementation of our existing values for the Universal Schedule as of Jan. 1 this year. Avera Health Plans completes a full file update for our provider fee schedules by July 1 each year to correspond with the annual changes performed by CMS to the Relative Value Units (RVU) and Medicare rates.

Additional new codes are added 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.

Reminder: Avera Health Plans and DAKOTACARE Consolidate Preauthorization, E&I and Preventive Lists for 2019

Reminder: Avera Health Plans and DAKOTACARE Consolidate Preauthorization, E&I and Preventive Lists for 2019

To better meet the needs of our members and the providers who serve them, Avera Health Plans and DAKOTACARE are taking steps to build a program that is both consistent and efficient.

To reach this goal, we are excited to announce that as of Jan. 1, 2019, the following lists were consolidated for Avera Health Plans and DAKOTACARE for fully insured groups and the Avera Health Employee Health Plan:

  • Preauthorization list – Note that coverage rules vary by plan, therefore, something may be listed on the preauthorization list that may not be covered on the plan.
  • Experimental and investigational list (E&I) – For all plans, E&I products and services are not covered.
  • Products and services list – For compliance with the Affordable Care Act.

To accomplish this consolidation, we took a close look at each of these lists from Avera Health Plans and DAKOTACARE. These were reviewed for clinical appropriateness based on utilization versus risk and evidence-based guidelines.

To find these consolidated lists for 2019, visit AveraHealthPlans.com or DAKOTACARE.com.

NCQA Accreditation

NCQA Accreditation

In December Avera Health Plans underwent survey for renewal of accreditation by NCQA (National Committee on Quality Assurance). Overall, the survey was successful and Avera Health Plans was granted “Commendable” status!

"Commendable" status is achieved by receiving an overall score of 80 or higher out of a possible 100 points. Avera Health Plans’ overall score was 81.92 out of 100. The total score is the sum of the score from three separate categories. The largest portion of the score comes from the standards. The standards account for 50 of the 100 possible points and Avera Health Plans received 49.23 out of the 50. The next largest share of the points come from our HEDIS (Healthcare Effectiveness and Data Information Set) score. HEDIS accounts for a possible 37 out of the 100 points and Avera Health Plans achieved 22.64 of the 37 possible points. CAHPS (Consumer Assessment of Healthcare Providers and Systems) is the last part of the score and accounts for a possible 13 points. Avera Health Plans scored 10.05 out of the 13 possible points on the last survey.

NCQA accreditation is based on a three-year cycle and Avera Health Plans will be up for renewal in the fall of 2021. However, HEDIS and CAHPS are submitted to NCQA annually and the status of the current accreditation could change depending on those scores. HEDIS and CAHPS also allow for the biggest opportunity for improvement in the overall score with only a combined score of 32.69 out of a possible 50 points.

Authorization Requests for Dental Services

Authorization Requests for Dental Services

For those of you submitting requests for dental services, just a few pointers:

  1. Fill out the authorization form completely and attach any needed, relevant information to support the requested services.
  2. Ensure any imaging/films contains the member name and date of birth.
  3. Email is preferred when sending the information to the Health Plan as the films or pictures are clearer and easier to read. Email to: HealthServices@AveraHealthPlans.com.

Following the above steps will help ensure your request is addressed in a timely manner and also helps prevent phone calls for both you and the Health Plan.

In the event you are requesting a dental pre-determination, submit the predetermination and accompanying information and/or documentation. This will be completed within 30 days.

Radiology Notifications

Radiology Notifications

Thank you all for your patience as we work through this new process. Here are a few tips to help facilitate the process:

  • Be sure to fill out the form completely, including the codes.
  • Fax numbers should reflect where you want the notification letter sent.
  • Depending on who is initiating the form (facility or clinic), please share the notification number with your counterpart. This helps streamline the process and eliminates duplication and phone calls.

If you would like to review the previous information on the notification process, please refer to the December 2018 ProviderView edition.