Provider Fast Facts

Provider Fast FactsDecember 2021 An eNewsletter from Sanford Health PlanRisk Adjustment 101What is risk adjustment?Risk adjustment is a modern payment model that uses bothdemographics and diagnoses to determine a risk score thatpredicts how costly care will be for the coming year. Riskadjustment allows the Centers for Medicare and MedicaidServices (CMS) to pay plans for the risk of the beneficiariesthey enroll. By risk adjusting plan payments, CMS canmake appropriate and accurate payments for enrolleeswith differences in expected costs. Increased accuracybenefits patients, providers and health plans.What is my role as a Provider?Providers have an important role to play in risk adjustment.An engaged partnership between the provider andthe health plan is vital to bringing valuable benefits toenrollees. For instance, insurers may use premiums andrisk adjustment payments to offer members enrollmentin exercise programs, case or disease management,transportation to medical appointments and other services.The health plan uses diagnosis codes that providers submiton claims to identify what types of programs are needed,and more specifically who needs them.Documentation and coding practices can be used for strongHierarchical Condition Categories (HCC) performance.Good clinical documentation along with accurate ICD-10diagnosis will assist in a complete clinical picture andallow the correct Risk Adjustment Factor (RAF) score to becalculated for proper payment.Risk scoresUnderstanding Hierarchical Condition Categories is agood place to start when learning about risk adjustment,particularly from a coding perspective. An HCC list isa list of diagnoses that have been assigned a value forrisk adjustment.To establish an HCC list, all conditions that are coded inICD-10-CM are organized into diagnosis groups of bodysystems or disease processes. These groups are thensubdivided into condition categories based on similar costpatterns. The final HCC list includes only the diagnoses thatare likely to impact long-term healthcare costs related toclinical and/or prescription drug management particular tothe demographics of the specific risk adjustment paymentmodel. Demographic factors used in addition to diagnosesfor risk score calculation include age, sex, disabledstatus, eligibility status and whether the member lives in acommunity vs. institution.Continued on page 2.1

Cover story continued.What Causes a Risk Score toIncrease or Decrease?For the program to capture therisk score of a patient accurately, aprovider must submit all conditionsaffecting the patient’s health statusat least once per calendar year onone or more claims. Risk scoresreset every January 1.If a chronic condition is notrecaptured from a previousyear, the patient’s risk score willdecrease for the current year.If additional conditions arereported, the patient’s risk scorewill increase from what it was inthe previous year.HistoryRisk adjustment methodologyfor Medicare Advantage was firstrequired in 1997 by the BalancedBudget Act. When CMS firstimplemented risk adjustment,hospital inpatient diagnoses werecollected to determine payment toMedicare Advantage organizations.In 2000, with the BenefitsImprovement and Protection Actof 2000, Congress mandated thatambulatory data also be collected.This change occurred graduallyand was fully implemented in2007 with completion of 100%risk adjusted payments for themajority of Medicare Advantageorganizations.The Medicare Prescription Drug,Improvement, and ModernizationAct established the prescriptiondrug benefit (Part D) to go intoeffect under risk adjustmentmethodology in 2006.Source: sf/files/2013RA101ParticipantGuide 5CR 081513.pdf/ File/2013 RA101ParticipantGuide 5CR 081513.pdfSanford Health Plan CaseManagement ProgramTo connect members with the right resources at the right time, SanfordHealth Plan offers case management services to all members with complexor high-risk health conditions. These services help our members betterunderstand their health while coordinating their care to develop andimplement a care plan that’s focused on their goals and health needs.The current case management programs and services offered by SanfordHealth Plan include:Very High-Risk Case Management:Members who have experienced catastrophic or life-changing events wherefunctional level may not return to previous baseline status or who haveinitiated hospice or palliative care.Complex Case Management:Members with multiple chronic conditions, catastrophic events, complex oruncontrolled health conditionsSpecialty Case Management Programs:Transplant: Members undergoing transplant evaluation or currently on alist for a transplant.Oncology: Members with an active or complicated cancer diagnosis.NICU: Newborns with complications or conditions requiring a neonatalintensive care stay.High-Risk Pregnancy: Expectant mothers with a high-risk pregnancy due tocarrying multiples or complicated medical conditions.Behavioral health: Members with substance-use disorders, depression,anxiety, bipolar disorder, schizophrenia or personality disorders withadmissions or emergency room use.Care Transitions — Medical or Behavioral Health: Members with inpatienthospitalizations for a medical or behavioral health need that is managed for30 days after discharge.Social Work: To address psychosocial needs, members with identifiedsocial determinants of health are referred to a social worker for assistanceto connect with community resources.For more information about any of our Care Management programs,or to refer a Sanford Health Plan member to one of our programs,please contact our Care Management Team at(888) 315-0884shpcasemanagement@sanfordhealth.org2

What is the No Surprises Act and whatdoes it mean for providers?The No Surprises Act was signed into law on Dec. 27, 2020. Provisionsof the law are scheduled to go into effect on Jan. 1, 2022, and SanfordHealth Plan is taking steps to comply with the regulation. The purposeof the No Surprises Act is to improve price transparency and protectpatients from receiving surprise medical bills.Providers and facilities cannot balance bill in the followingsituations: Out-of-network emergency covered items and services Covered medical items and services performed byan out-of-network provider at an in-network facility(ex: patient undergoes planned surgery at in-networkhospital with in-network provider but receives anesthesiafrom an out-of-network anesthesiologist, patient hasbloodwork done at an in-network facility, but the testingis outsourced to an out-of-network laboratory.) Out-of-network air ambulance serviceThe law requires carriers to reimburse at the Qualified PaymentAmount (QPA) for certain out-of-network providers and services inaddition to emergency services. The QPA is generally the median ofcontracted rates for a specific service in the same geographic regionwithin the same insurance market as of Jan. 31, 2019. Additionally,providers are not able to balance bill members for the differenceof the billed amount and the QPA. If the provider does not acceptthe QPA reimbursement, the Act requires providers to work withinsurers to negotiate payment, referred to as the Open NegotiationPeriod. If the insurer and the provider are unable to reach agreement,an Independent Dispute Resolution (IDR) can be initiated, where anoutside party will determine the final reimbursement amount.How Sanford Health Plan isplanning to be in compliancewith January 1, 2022 NoSurprises ActBeginning Jan. 1, 2022, CMS will require selffunded plans and fully insured individual andgroup plans to establish a provider directoryverification process and establish a procedurefor removing providers or facilities withunverifiable information. Sanford Health Planjoins more than 425 payers across the nationthat are enlisting Quest Analytics servicesto implement a robust process to verify ourprovider directory.What this means for you as a provider:You will receive communication from ourpartner, Quest Analytics, every 90 days to verifythe details we have in our provider directory.Once the details are sent back and verified,Quest/Sanford Health Plan will update ourdirectories within two business days of receivingthe provider updates. If no response is received,we are required to remove the provider from ourprovider directory until information is verified ascorrect. Prompt response is key.Important URL: sprevent-surprise-billingFor more information on the implementation requirements of theNo Surprises Act, visit: cms.gov/nosurprises3

Sanford Health Plan becomesThird Party Administrator for theself-insured plan for Mandan,Hidatsa and Arikara (MHA) NationStarting Jan. 1, 2022, Sanford Health Plan willbe taking over the self-funded plan, MHA Nation– Three Affiliated Tribes, which was previouslyadministered by the Boon group.Claim PaymentsYou can easily check a claim status onlineHERE.You will need either Option 1 or Option 2below to obtain this detail:1Provider Tax ID OR NPI2Sanford Health Plan claimnumber and billed amountSome details regarding this product plan are:Sanford Health Plan Claimnumber and date of service Original effective date Jan. 1, 2022 “Three Affiliated Tribes” will be printedon ID cards Members use a specific customer servicephone number: (877) 701-0792NEWProvider RelationsEducation EventsThe Sanford Health Plan Provider Relationsteam invites you to save time on yourcalendar for our first education session Dec.17, 2021, at 10 a.m. for an education sessionwith our Senior Provider Relations Specialists.The goal of this meeting will be to sharewhat’s happening at Sanford Health Plan andprovide updates that help keep you on track.Use this LINK to register for our first session.Provider Manual UpdatesWatch our Provider webpage for a newonline version of our Provider Manual! Thelink, along with our current pdf versionof the manual, is located on the ProviderResource Forms and Resources page HERE.4

Policy and BenefitReimbursement UpdatesBelow, you’ll find a listing of the policies that are new,updated or deleted. The policies are located on oursecure portal under “Quick Links — Policies & MedicalGuidelines”.If you do not have portal access you can requestaccess at this HERE.For additional questions please call us at (800)601-5086 Option 2, followed by Option 4 to reachProvider Relations.New Policies: Gastrointestinal ManometryUpdated Policies:Co-Surgeon / Team Surgeon P olicy was updated in April 2021, however,implementation was delayed to 1/1/22. C laims submitted after 1/1/22 will processper policy which includes two changeslisted below:Successful PriorAuthorization SubmissionsWe have had great success with providers submittingprior authorizations electronically on our Provider Portal.As a reminder this requirement went into effectOct. 1, 2020.Authorizations (both Medical and Pharmacy) that arenot urgent will be returned to providers when sent tous in paper form and could delay your authorization.Please see the instructions below to help you navigatehow to submit an electronic authorization.SANFORD EMPLOYEES AND INTERNAL USERS:Please see the training resource HERE, or sign up foradditional classes in the Sanford Success Center.EXTERNAL PROVIDERS: Please submit authorizationrequests via Provider Portal HERE. For questions,please contact Provider Relations at (800) 601-5086.Additional tips are below:1. R equests should be made electronicallythrough our Provider Portal to ensure real timedeterminations, quicker turn-around times Consistent with CMS, eligible servicesfor each co-surgeon and with modifier62 appended, will be reimbursed at62.5% of the fee schedule, subject toadditional multiple procedure reductions,if applicable.2. S electing the correct “Auth Type” will route the

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