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ProviderView Quarterly eNewsletter

November 2017

Digital Breast Tomosynthesis (3-D Mammo) to Be Covered Beginning Jan. 1, 2018

Digital Breast Tomosynthesis (3-D Mammo) to Be Covered Beginning Jan. 1, 2018

Currently, Avera Health Plans categorizes digital breast tomosynthesis services as experimental and investigational. Effective Jan. 1, 2018, these codes will be removed from the experimental and investigational list and be covered when medically necessary subject to all of the terms and conditions of the member’s coverage documents. When included as part of a covered screening service, the digital breast tomosynthesis will also be covered under the member’s applicable screening benefits. The codes for these services currently include the following:

  • 77061 Digital breast tomosynthesis; unilateral
  • 77062 Digital breast tomosynthesis; bilateral
  • 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
  • G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206)

Postpartum Depression Screening

Postpartum Depression Screening

Avera Health Plans recognizes the importance of screening new mothers for postpartum depression at the postpartum care visit. According to the American College of Obstetricians and Gynecologists (ACOG), up to 25 percent of women experience postpartum depression. OB-GYNs and family practice physicians are integral to screening women for postpartum depression and can manage its impact on maternal health. Avera Health Plans’ goal is that a total of 80 percent of postpartum patients are screened for postpartum depression. Avera Health Plans measures the commercial group and Marketplace individual populations separately.

Postpartum Depression Addressed
at Post-Partum Office Visit

Number Compliant

Percent Compliant

Commercial group

118 (out of 231 cases)


Marketplace individuals

179 (out of 305 cases)


Combined compliance

297 (out of 536 cases)


Avera Medical Group hosted the recent AMG OB-GYN Update: Mental Wellness in Pregnancy and Postpartum This recorded event covers:

  1. Review the recent ACOG practice bulletin regarding anxiety in pregnancy and postpartum depression
  2. Discuss the general treatment options for postpartum depression and anxiety in pregnancy
  3. Review the process for same-day referrals at Avera Health

Age Limit Implemented on Codeine- and Tramadol-Containing Products

Age Limit Implemented on Codeine- and Tramadol-Containing Products

Effective Oct. 1, 2017, Avera Health Plans placed an age limit of 12 years and older on all codeine-containing and tramadol-containing products. No requests for codeine-containing or tramadol-containing products will be accepted for children 0-11 years of age.

This change was in response to recent recommendations by the FDA.

On April 20, 2017, the FDA issued a safety announcement restricting the use of codeine and tramadol medicines in children due to serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years of age.

These medicines should not be used in children younger than 12 years and should also be limited in children younger than 18 who are obese or have conditions such as obstructive sleep apnea or severe lung disease.

FDA also recommended against the use of codeine and tramadol in breastfeeding mothers due to the risk of serious adverse reactions in breastfed infants, including excess sleepiness, difficulty breastfeeding or serious breathing problems that could result in death.

To learn more, visit the FDA website. (LINK:

Follow-Up Care for Children Prescribed Attention Deficit and Hyperactivity Disorder (ADHD) Medication

Follow-Up Care for Children Prescribed Attention Deficit and Hyperactivity Disorder (ADHD) Medication

Annually, Avera Health Plans reviews the rates for follow-up care for children ages 6-12 who were prescribed an ADHD medication. Two rates are measured:

  • Initiation Phase: the percentage of members 6-12 years of age at the prescription start date with a prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day initiation phase.
  • Continuation and Maintenance Phase: the percentage of members 6-12 years of age as of the prescription start date with a prescription dispensed for ADHD medication, who remained on the medication for at least 201 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (nine months) after the Initiation Phase ended.

Avera Health Plans received the following rates for follow-up care for children prescribed ADHD medication initiation and continuation phases for the 2017 HEDIS measurement period, which measures calendar year 2016.

Follow-Up Care for Children
Prescribed ADHD Medication





Initiation Phase







Continuation and Management Phase







Avera Health Plans has found that part of the reason for lack of follow-up is a gap in parental education in the importance of follow-up. As an intervention to this, Avera Health Plans will send letters to parents of children with a newly prescribed ADHD medication and to the prescriber to educate them on the follow-up schedule and its importance.

Timely Record Completion Ensures Good Coordination of Care

Timely Record Completion Ensures Good Coordination of Care

To ensure patients receive the best available care, information must be shared between all members of the care team – including specialists, behavioral health providers and primary care. Timely medical record documentation facilitates the ability of the physician and other health care professionals to evaluate and plan for each patient’s immediate treatment and to monitor the patient’s health over time.

Annually, Avera Health Plans evaluates provider satisfaction with the flow of information to and from specialists, behavioral health providers and primary care. We evaluate accuracy, sufficiency, timeliness, clarity and frequency of information.

Deficits in communication and information transfer are common and may adversely affect patient care. Interventions, such as more timely discharge summaries to facilitate follow-up may help with more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

Top 5 Reasons UMR and EDI Claims Rejected

Top 5 Reasons UMR and EDI Claims Rejected

Q: Can the billing provider address be a P.O. box or lock box?
A: The billing provider address must be a physical street address and cannot be a P.O. box or lock box.
On the 5010 EDI format, there is a pay-to address in addition to the physical address if the provider prefers to send payments to another location. This pay-to address can be a P.O. box or lock box. The pay-to address will have the same name as the physical address provided. Please note: Billing provider must have a physical address. If using the pay-to address for P.O. box or lock box, the NPI and Tax ID must also match the billing provider's NPI and Tax ID or claims will reject.

Q: How can I check to see if my NPI is formatted correctly?
A: NPI’s submitted on the 5010 EDI format must be a 10-digit number — nine numeric digits followed by one numeric check digit. If you send the “XX” qualifier in NM108 and improperly format your NPI in NM109 claims will reject. You can confirm your NPI by searching the NPI Registry or you can check the NPI format on this NPI Check Digit Calculator.

Q: Line rendering is missing primary ID qualifier — why is this reject happening?
A: When NPI or legacy Provider Identification Numbers are placed on a claim they need to be preceded by an ID code qualifier. If the ID is missing claims will reject.
ID Code Qualifier:
ID Qualifier = 2310B NM108, 2310B REF01
NPI = 2310B NM108 (XX)

Q: Can the CMS 1500 or 837P form contain both ICD-9 codes and ICD-10 codes?
A: Payors will return claims to care providers that contain both ICD-9 and ICD-10 codes on the same claim. Per CMS guidance, care providers must split claim submissions that carry over the Oct. 1, 2015, compliance date so services provided prior to that date are not reported in the same claim as services provided on or after Oct. 1, 2015. These free ICD-10 Code Specific/Specialty Documentation-focused webinars provide more information.

Q: What information is crucial for billing electronic ambulance claims?
A: To ensure correct claim processing include the following:

  • The CR1 segment (Ambulance transport information is required)
  • The CRC segment (Ambulance certification is required)
  • The DTP segments (Includes admission date and discharge date)
  • The NTE segment (Use to report the condition of the patient and reason for transport)
  • Loop 2310D (Full name of individual or organizational entity rendering the service)
  • Example: NM1*DD*1*SMITH*JOHN*S***34*123456789~
  • Loop 2310C segments (Claim level information)

Care Management Programs Currently Available for Our Members

Care Management Programs Currently Available for Our Members

Chronic and/or Complex Case Management
Participants are empowered to take control of their health care needs across the care continuum. Eligible members may have serious complex conditions that may be disabling or life threatening, requiring treatments and/or services across a variety of domains of care (medical and social).

Avera registered nurses will now make calls to eligible members and perform the following:

  • Thorough assessment
  • Development of an individualized care plan
  • Weekly documented interactions
  • Education for condition management
  • Follow up and track progress made toward goals including collaboration with the member’s provider

Disease Management
This program helps members regain optimum health or improved functional capability. Disease Management is offered to members diagnosed with the following diseases:

  • Asthma (includes children)
  • Coronary artery disease (CAD)
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes (includes children)
  • Heart failure (HF)

The participant is assigned to a registered nurse team that conducts a comprehensive assessment of the participant’s disease status, contributing co-morbid conditions, medication regimen and treatment plan approved by the primary care physician. Individualized intervention strategies and goals are developed with each participant.

Providers and/or members may call our Care Management team toll-free at 1-888-605-1331, option 3, 8 a.m. to 5 p.m. CT, Monday through Friday. Care Management programs are NCQA accredited.

Facet Injections

Facet Injections

2017 InterQual Criteria notes a change in one of the criteria points for facet injections. This is in regards to pain relief. Previous criteria used the traditional threshold of pain relief of greater than 50 percent. However, the criteria has been modified and now states pain relief of greater than 80 percent*. You will see this change noted on the Preauthorization Form for Facet Joint Injection located on the Avera Health Plans website. Keep in mind this documentation is needed for authorization purposes and completing the form accurately and in its entirety helps mitigate phone calls and delays in the authorization process.
*(Watters et al., J Neurosurg Spine 2014, 21: 79-90)

List of Experimental and Investigational Products and Services Maintained Online in the Provider Portal

Panel 2

List of Experimental and Investigational Products and Services Maintained Online in the Provider Portal
Avera Health Plans maintains a list of codes that we consider experimental and investigational online behind security in our provider portal. After logging in with your secure user credentials, the list can be found under Provider Resources > Policies > Medical Policies where it is maintained as a linked document under the Experimental Investigational and Unproven Policy.

Codes found on this list if billed, are denied as a provider liability when billed by a participating provider. When members have been given advance notice and signed a patient waiver demonstrating informed consent of their financial liability, a participating provider can retain their rights to bill the member for these services. Providers must follow the guidance found in the Avera Health Plans Provider Manual, Section 4.7 – Patient Waivers.

If there are any questions about the process for using a patient waiver, please contact a member of our provider relations team and we will be happy to answer your questions.

Screening Rates Increased through Proactive Interventions

Screening Rates Increased through Proactive Interventions

In 2016, Avera Health Plans took steps to identify and encourage members to access breast, cervical and colorectal cancer screenings and for members with diabetes to access eye exams and achieve more consistent Hba1c blood testing.

To impact these areas, Avera Health Plans began a campaign of proactive letters and phone calls to target members and encourage them to take advantage of these needed interventions. An additional quality review nurse was employed to assist in the process. Members were identified through electronic medical records, including taking steps to exclude members who should be removed from the focus group.

The efforts proved successful, showing significant improvement in most areas, ensuring that members most in need of care receive the right interventions at the right time.

Percentage of Members Compliant - Commercial

Percentage of Members Compliant - Marketplace

Additionally, these efforts have made a positive impact on Avera Health Plans’ Healthcare Effectiveness Data and Information Set (HEDIS) results for the 2016 measurement year. HEDIS (Healthcare Effectiveness Data and Information Set) is a tool used by Avera Health Plans to measure performance on important quality metrics. Over 90 percent of health plans use this measure, making it easy to compare our performance against local and national numbers.

Avera Health Plans will continue to focus on the same measures for 2017 HEDIS with an additional focus on immunizations for adolescents and is planning to join efforts with the Avera Medical Group “Give it a Shot” campaign, the Immunization Coalition and Pharmacy Immunizations. Additionally, Avera Health Plans is working on proactive efforts such as mailings and phone calls to members, and focusing on those who have not seen their provider for wellness exams, etc.

New Pharmacy Benefits Manager, Website for Preauthorizations

New Pharmacy Benefits Manager, Website for Preauthorizations

Effective Jan. 1, 2018, Avera Health Plans will implement a new Pharmacy Benefits Manager, CVS Caremark™.
Avera Health Plans has launched an updated web site for providers to access preauthorization request requirements at At this site, you will have access to:

  • Services requiring preauthorization
  • General and procedure-specific preauthorization forms to fax
  • Email addresses and fax numbers for preauthorization submission
  • 2018 drug formulary lists