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ProviderView Quarterly eNewsletter

September 2018

Contract Deadline Oct. 1

Contract Deadline Oct. 1

Avera Health Plans and DAKOTACARE are working together to contract with physicians and providers for both health plans under a single universal contract.

New contracts, which will go into effect Jan. 1, 2019, were sent to affected providers in April.

To ensure patients experience no disruption in their network coverage, please return the signed contract by Monday, Oct. 1.

If you have any questions, contact our provider relations team: Mike Dooley at 605-322-4634; Scott Jamison at 605-274-3141; Michael Nour at 605-322-4596; or Micah Linn at 605-322-3643.

Important LiveNOW Screening and Coding Information

Important LiveNOW Screening and Coding Information

LiveNOW is Avera’s employee well-being program, designed to build a stronger connection between Avera employees and their primary care physician and help keep them healthy and well.

Avera Health Plans has worked with participating providers to develop the necessary information needed to operationalize this if you have participating employees schedule clinic visits to complete their requirements.

Metrics needed:

Avera Health Employee Health Plan enrolled employees can qualify for premium savings* by:

  • Attending an on-site LiveNOW screening event at select Avera facilities, OR
  • Scheduling a LiveNOW biometric screening with their primary care provider and asking them to address the following metrics in addition to the general documentation for a physical:
    • Lab – Lipid Panel*
    • Lab – Glucose*
    • Lab – Tobacco/Nicotine Metabolites
    • Vitals Measurement – Waist Circumference
    • Vitals Measurement – Pulse
  • These measures should be documented by a provider on the Alternative Method Screening form. It is the responsibility of the participant to submit the form to LiveNOW.

To learn more about LiveNOW program and reward eligibility, visit


All additional measures will be covered 100 percent under the wellness CPT Codes of:

New Patient CPT Codes

  • 18-39 years old – 99385 + 80061 + 82947+ 80323
  • 40-64 years old – 99386 + 80061 + 82947+ 80323
  • 65+ years old – 99387 + 80061 + 82947+ 80323

Established Patient CPT Codes

  • 18-39 years old – 99395 + 80061 + 82947 + 80323
  • 40-64 years old – 99396 + 80061 + 82947 + 80323
  • 65+ years old – 99397 + 80061 + 82947 + 80323

Documentation and billing*:

Document and bill these exams under one of these applicable diagnosis codes:

  • Z00.00 General Medical Exam w/o Abnormal Finding
  • Z00.01 General Medical Exam w Abnormal Finding
  • Z01.419 Adult Female Pelvic/Gynecological Exam w/o Abnormal Finding
  • Z01.411 Adult Female Pelvic/Gynecological Exam w Abnormal Finding
  • Z13.220 Screening diagnosis code for lipid panel
  • Z13.1 Screening diagnosis code for glucose testing
  • Z13.9 Screening diagnosis code for tobacco/nicotine metabolites

*Screening codes must be the primary diagnosis in order to cover at 100 percent. A more definitive diagnosis should be coded as a secondary diagnosis.


LiveNOW biometric screening must be completed and the Alternative Method Screening form must be submitted by Nov. 16, 2018, for participants to qualify for the 2019 LiveNOW reward. In order to qualify for the 2019 LiveNOW reward, participants must complete both the health assessment (questionnaire) and the LiveNOW screening by Nov. 16, 2018.

More information: To learn more, view the LiveNOW Physician and Provider Q&A.

For benefit and insurance eligibility information, visit or call 1-888-322-2115.

John Morrell Drug Preauthorizations

John Morrell Drug Preauthorizations

Preauthorizations for drugs covered on the pharmacy benefit are handled by OptumRx, the pharmacy benefits manager for John Morrell. You may contact OptumRx at 1-877-358-6395 for assistance with preauthorization questions and requests.

Preauthorization is still handled by Avera Health Plans with drugs covered on the medical benefit. You may fax your preauthorization request to 1-800-269-8561 for review. Preauthorizations received through OptumRx will not be accepted for medical claims reimbursement.

If you have questions or concerns, please contact our Service Center at 605-322-4545 or toll-free at 1-888-322-2115, 8 a.m. to 5p.m. CT, Monday through Friday.

Behavioral Health Appointment Access Standards

Behavioral Health Appointment Access Standards

To ensure Avera Health Plans members have timely access to services, providers are required to comply with set standards for appointment access.

The minimum appointment access standards are:

Behavioral Health Appointment Access Standards

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.

Clinical Documentation Improvement

Clinical Documentation Improvement

As part of Avera Health Plans Quality programming, medical records are frequently reviewed for various reasons, including but not limited to: quality of care reviews, risk adjustment, and HEDIS (Healthcare Effectiveness Data and Information Set) measures. In order to ensure excellent care for the members served by Avera Health Plans, the clinical information in the medical record must be clearly documented in order to be considered complete for the purposes described above. For example, members with diabetes have multiple exams that must also be completed within a specific time period in order to satisfy HEDIS measures, such as diabetic eye exam, foot exam, and documented Hg A1c values. As an issuer accredited by NCQA (National Committee for Quality Assurance), Avera Health Plans must support the completion of these exams via two methods: administrative means (a claim with an approved CPT code) or medical record review by a clinician within the health plan. If the documentation is not adequate, Avera Health Plans cannot consider that record complete and is not valuable for the purposes of HEDIS.

Because Avera Health Plans strives to be the insurance company of choice for employers and individuals within the Avera footprint, continued demonstration of the highest quality of care through accurate and complete documentation is essential. To learn more about Clinical Documentation Improvement education and activities, please contact Sara Hansen, Manager of Risk Adjustment, at 605-322-2329 or by email at

Out-of-Network Referral Reminders

Out-of-Network Referral Reminders

At Avera Health Plans, quality, affordable care with an extensive provider network is a top priority for the members we serve. While it is preferred that members receive all of the care within the established provider network, there are instances when that is not possible. As a reminder, contracted providers are required to refer their patients to other in network providers when a higher level of care is necessary for the member.

For Avera Health Plans to consider in network benefits, some examples of criteria evaluated includes:

  • Is the referring provider of the same specialty as the preferred provider?
  • Is the specialty available in-network?
  • Does the service requested meet medical necessity (InterQaul®) criteria?
  • Does the member have a considerable distance to travel to visit an in-network provider?

Each request for in-network benefits with an out-of-network provider is evaluated by a medical professional at Avera Health Plans, including physicians and nurses. It is recommended that providers submit as much information as possible when requesting in-network benefits for an out-of-network service, allowing at least 14 days for Avera Health Plans to review and respond. Following a determination, the referring provider, referred to provider and/or facility, and the member receive a letter explaining the decision and rationale, as well as additional options afforded to the member.

If you have questions about referring a member out-of-network, please call our Service Center at 1-888-322-2115 or 605-322-4545, 8 a.m. – 5 p.m. CT, Monday - Friday.