Search Results

2012 PCA Provider Agency Annual Renewal Assurance Statements — PW_2011_069
Form — Personal Care Assistant (PCA)
This form is for Personal Care Assistance (PCA) Provider Agencies to use when submitting annual assurance statements to ensure compliance with applicable provisions of the Minnesota Statute related to PCA Provider Agencies that offer Extended State Plan PCA Services.
Last Updated: 10/22/2012

Adjustment Request Form — PW_2008_042
Form — Claims
Providers should use this form to request an adjustment to a previously processed claim.
Last Updated: 1/9/2012

Agreement to Use Designated Provider — PW 2009 201/H2416_PW_2009_5201/H2926_PW_2009_5201
Form — County Case Managers
The member must sign this form to designate from which provider his/her waiver obligation should be deducted when claims are received at PrimeWest Health.
Last Updated: 2/23/2010

Application for Title XIX Home and Community-Based Waiver Services and Alternative Care (135 Day Eligibility) Program Information and Signature Sheet — DHS-2727-ENG
Form — County Case Managers
This form is used to document that a member has received the information needed from his/her county in order to live in the community or in a long-term care facility.
Last Updated: 3/7/2013

Appointment of Representative Form — CMS-1696 H2416_PW_2011_1068/H2926_PW_2011_3068
Form — Prime Health Complete (HMO SNP)
Members should use this form to give another person permission to act as their Authorized Representative. Member of all plans may use this form to document and identify an Authorized Representative, but it is required for a Medicare Appeal.
Last Updated: 7/11/2011

Appointment of Representative Form — CMS-1696 H2416_PW_2011_1068/H2926_PW_2011_3068
Form — PrimeWest Senior Health Complete (HMO SNP)
Members should use this form to give another person permission to act as their Authorized Representative. Member of all plans may use this form to document and identify an Authorized Representative, but it is required for a Medicare Appeal.
Last Updated: 7/11/2011

Brown Bag It Checklist/My Medicine Record — PW_012013_062
Form — Member
Checklist reminding members what to bring to appointments with their primary care providers. Includes a form for members to document different aspects of their medications, such as the prescribing information.
Last Updated: 2/12/2013

Care Coordination Tier Assessment Tool — PW_2011_404
Form — Service Authorizations
This tool is intended to assess the overall complexity of Health Care Home patients by grouping them into complexity tiers based on the number of major chronic condition categories that apply to them. This tool should be submitted with the Medical Service Authorization Request Form.
Last Updated: 10/19/2011

Care Coordination/Case Management Referral Form — PW_042013_317
Form — Care Management
Providers use this form to refer a member to care coordination and/or case management.
Last Updated: 4/29/2013

Care Plan Signature Page — PW_2010_153/H2926_PW_2010_5153
Form — County Case Managers
This form should be used by case managers along with the electronic care plan for members with Prime Health Complete (HMO/SNBC), Complex Case Management, or Targeted Case Management. The form should be printed and signed by the member, case manager, and any other applicable parties.
Last Updated: 3/29/2013

Case Management PCP Letter — PW_2007_066
Form — County Case Managers
County case managers should use this letter to identify themselves to a member's primary care provider; includes contact infomation.
Last Updated: 11/18/2011

Case Management Referral Form — PW_022013_160
Form — Care Management
Providers use this form to refer a member to case management.
Last Updated: 2/21/2013

Charge Ticket — PW_2006_083R_04_11
Form — Maternal Child Health
C&TC providers can use this charge ticket to capture each component of the C&TC
Last Updated: 4/5/2011

Child & Teen Checkups (C&TC) Online Resources — WEB_052013_012
Form — Maternal Child Health
This is an online child and teen checkups (C&TC) form from the Minnesota Department of Health.
Last Updated: 5/8/2013

Children's Residential Mental Health (Rule 5) Treatment Facility Notification — PW_2009_069R01_13
Form — Mental Health
Form used by county partners and providers to notify PrimeWest Health of a member's admission to a Children's Residential Mental Health Rule 5 facility
Last Updated: 3/27/2013

Children's Residential Mental Health (Rule 5) Treatment Facility Notification — PW_2009_069R01_13
Form — Service Authorizations
Form used by county partners and providers to notify PrimeWest Health of a member's admission to a Children's Residential Mental Health Rule 5 facility
Last Updated: 3/27/2013

Claims Attachment Cover Sheet — PW_2009_227
Form — Claims
Providers should use this form to attach information to a claim per Administrative Uniformity Committee (AUC) guidelines.
Last Updated: 3/26/2010

Clinic Complaint Reporting Form — PW_2008_142
Form — Appeals & Grievances
Use this form each quarter to report complaints to your facility from PrimeWest Health members. It is due quarterly even if there are no complaints.
Last Updated: 3/7/2013

Customized Living (CL) Provider Council Membership Application — PW_2012_120
Form — Customized Living
Application for membership in Regional Customized Living (CL) Provider Council
Last Updated: 7/6/2012

Designation of Personal Care Assistance (PCA) Billing Person — PW_2010_305_DHS_6000_ENG
Form — Contracting
Form for PCA providers to use when designating PCA billing staff. PrimeWest Health's version of DHS-6000-ENG.
Last Updated: 10/18/2010

DHS PMAP SNF Communication Form — DHS-4461-ENG
Form — Service Authorizations
Nursing facilties should complete and submit this form to PrimeWest Health when admitting an MSC+ member. It is used to verify claims.
Last Updated: 3/13/2013

Dialectical Behavior Therapy (DBT) Authorization Request Form — PW_2011_284
Form — Service Authorizations
Use this form to request member authorization for dialectical behavior therapy intensive outpatient services provided by a DHS-certified program
Last Updated: 6/1/2012

Disclosure of Ownership and Control Interest — PW_2011_026
Form — Contracting
Providers must fill out this form to disclose any ownership or controlling interest in contracted facilities.
Last Updated: 8/17/2012

Disease Management/Chronic Care Improvement Program (DM/CCIP) Provider Satisfaction Survey — PW_2008_149R_02_13
Form — Disease Management
Providers can fill out this survey to let PrimeWest Health know how well we are meeting our members’ disease management needs.
Last Updated: 2/12/2013

Disease Management/Chronic Care Improvement Program (DM/CCIP) Referral Form — PW_2009_231R_02_13
Form — Disease Management
Providers fill out and submit this form online to refer a member into a Disease Management program(s).
Last Updated: 2/12/2013

Disenrollment Form - Special Needs BasicCare (SNBC) 2013 — PW_2012_009
Form — Member
Members should use this form to request to cancel their enrollment in PrimeWest Health's Special Needs BasicCare (SNBC) program
Last Updated: 1/12/2012

Elderly Waiver CDCS Conversion Rate Request (Attachment D) — WEB_2012_003
Form — County Case Managers
Request form for Elderly Waiver CDCS conversion rate
Last Updated: 3/14/2012

Elderly Waiver Conversion Rate Request (Attachment C) — WEB_2012_002
Form — County Case Managers
Request form for Elderly Waiver conversion rate
Last Updated: 3/14/2012

Electronic Remittance Advice (835) Registration Form for 837 Institutional/Professional (837 I/P) Claims — PW_2009_367
Form — Claims
This form is used to collect clearinghouse information from providers for 835 registration
Last Updated: 8/2/2012

Enrollment Form - Special Needs BasicCare (SNBC) 2013 — PW_2012_008
Form — Member
Members should use this form to request enrollment into PrimeWest Health's Special Needs BasicCare (SNBC) program
Last Updated: 1/5/2012

Enteral Nutrition Service Authorization Form — PW_2006_064R_11_11
Form — Service Authorizations
Providers should use this form to submit a request for coverage for enteral nutrition.
Last Updated: 11/30/2011

Facility Change/Update Form — PW_2010_320R_02_11
Form — Contracting
Providers should use this form to submit demographic changes for their facility.
Last Updated: 2/15/2011

Facility Information for Non-Contracted Providers — PW_032013_250
Form — Claims
Non-contracted providers should complete this form with their facility information.
Last Updated: 4/4/2013

Fall Risk Assessment — PW_2012_073
Form — County Case Managers
County case managers can complete this fall risk assessment tool to help identify a member's risk for falling.
Last Updated: 6/29/2012

Falls Report – PrimeWest Senior Health Complete (HMO SNP)/Minnesota Senior Care Plus (MSC+) — PW_2011_425
Form — County Case Managers
County case managers should complete this form when a PrimeWest Senior Health Complete/MSC+ member experiences a fall.
Last Updated: 6/29/2012

Fast Track Intervention Strategies (FTIS) Notification and Update Form — PW_2012_031R_02_13
Form — County Case Managers
County case managers and care coordinators complete this form to indicate an initial notification or update of FTIS.
Last Updated: 3/11/2013

Fitness Professional Credentialing Form — PF_2008_015R_02_13
Form — Credentialing
Providers should use this form to enroll a new fitness professional.
Last Updated: 3/29/2013

Health Care Directive — PW_2007_035R_03_11
Form — Member
A Health Care Directive is a written document that informs others of your wishes about your health care.
Last Updated: 3/28/2011

Health Risk Assessment — PW_2012_324
Form — County Case Managers
The HRA is used by case managers or care coordinators to provide members with a tool to evaluation their health risks and quality of life. This form can be completed by the case manager, care coordinator, or the member and can be conducted in person, over the telephone, or self-completed by the member. The PraPlus calculation/scoring sheet completed by the case manager or care coordinator must accompany the HRA.
Last Updated: 2/21/2013

Health Risk Screening Additional Questions to the PraPlus Screening — PW_2010_214R_08_11
Form — County Case Managers
Additional questions to the PraPlus screening. This form should be filled out by the member's county case manager and kept on file with the county.
Last Updated: 8/25/2011

Home and Community Based Notice of Action — PW_2006_012R_07_12
Form — County Case Managers
County case managers should use this form to notify PrimeWest Health that they are denying, terminating, or reducing services provided under the EW program.
Last Updated: 7/3/2012

Home and Community Based Notice of Action — PW_2006_012R_07_12
Form — PrimeWest Senior Health Complete (HMO SNP)
County case managers should use this form to notify PrimeWest Health that they are denying, terminating, or reducing services provided under the EW program.
Last Updated: 7/3/2012

Home and Community Based Waivered Services Provider Enrollment Application — PW_2008_152R_08_10
Form — Contracting
HCBS Provider Enrollment Application
Last Updated: 8/9/2010

Hospice Update to PrimeWest Health — PW_2009_118
Form — County Case Managers
County case managers should complete and submit this form when a PrimeWest Health member is admitted to hospice.
Last Updated: 12/28/2011

Hospice Update to PrimeWest Health — PW_2009_118
Form — Prime Health Complete (HMO SNP)
County case managers should complete and submit this form when a PrimeWest Health member is admitted to hospice.
Last Updated: 12/28/2011

Hospice Update to PrimeWest Health — PW_2009_118
Form — PrimeWest Senior Health Complete (HMO SNP)
County case managers should complete and submit this form when a PrimeWest Health member is admitted to hospice.
Last Updated: 12/28/2011

Individual Community Support Plan (ICSP) Adult Mental Health Targeted Case Management (MH-TCM) — PW_2010_373
Form — County Case Managers
This document is for adults receiving mental health targeted case management.
Last Updated: 6/30/2011

Individual Community Support Plan (ICSP) Adult Mental Health Targeted Case Management (MH-TCM) — PW_2010_373
Form — Mental Health
This document is for adults receiving mental health targeted case management.
Last Updated: 6/30/2011

Individual Family Community Support Plan (IFCSP) Children’s Mental Health — PW_2010_372
Form — County Case Managers
This document is for children receiving mental health targeted case management.
Last Updated: 6/30/2011

Individual Family Community Support Plan (IFCSP) Children’s Mental Health — PW_2010_372
Form — Mental Health
This document is for children receiving mental health targeted case management.
Last Updated: 6/30/2011

Individual PCA Information Change Form — PW_2011_459 (DHS-5716-ENG)
Form — Credentialing
Use this form to notify PrimeWest Health when a PCA leaves your organization or has a change to his/her last name.
Last Updated: 11/23/2011

Individual PCA Relationship Acknowledgement — PW_2011_382_DHS_6426_ENG
Form — Personal Care Assistant (PCA)
Personal Care Assistants (PCAs) complete this form to disclose their relationship to PrimeWest Health members for whom they are providing services. PrimeWest Health's version of DHS-6426-ENG.
Last Updated: 9/29/2011

Interdisciplinary Care Team (ICT) Assessment Notification — PW_2012_127
Form — County Case Managers
County case managers should use this form to notify an Interdisciplinary Care Team (ICT) member other than the primary care provider that the ICT has scheduled an assessment and is requesting input. (The form for primary care provider notification of an ICT meeting is PW_2011_458, Provider Assessment Notification.)
Last Updated: 3/22/2012

Internal Revenue Service W-9 — Form W-9 (Rev. 10-2007)
Form — Contracting
This form is required for all providers billing PrimeWest Health for services rendered
Last Updated: 4/4/2011

Lead Agency Case Manager/Worker Communication Form — DHS-5181-ENG
Form — County Case Managers
This form should be used by county case managers and county financial workers to communicate changes to a member's financial or waiver status.
Last Updated: 3/7/2013

Lead Agency Case Manager/Worker Communication Form — DHS-5181-ENG
Form — PrimeWest Senior Health Complete (HMO SNP)
This form should be used by county case managers and county financial workers to communicate changes to a member's financial or waiver status.
Last Updated: 3/7/2013

LTC Screening Document – AC, BI, CAC, CADI, EW, MSC+, MSHO, SNBC — DHS-3427-ENG
Form — County Case Managers
The Long Term Care (LTC) Screening Document is used to enter results of a Long Term Care Consultation (LTCC) into the Medicaid Management Information System (MMIS).
Last Updated: 3/7/2013

MA Member Rights — PW_2011_009
Form — Care Management
County case managers should attach this document to the care plan for the member.
Last Updated: 2/11/2011

MA Member Rights — PW_2011_009
Form — County Case Managers
County case managers should attach this document to the care plan for the member.
Last Updated: 2/11/2011

Medical Assistance (MA) Home Care Fax Form - For Home Care Provider Use Only — PW_2010_303_DHS_4074_ENG
Form — Service Authorizations
This form is used to request initial and continuing Service Authorization for skilled nurse, home health (HH), and private duty nursing (PDN) services. It is also used to request temporary changes in existing Service Authorizations for skilled nurse, HH, PDN, and Personal Care Assistant (PCA) services. This form is PrimeWest Health's version of DHS-4074-ENG.
Last Updated: 10/20/2010

Medicare Part D Over-the-Counter List — H2416_H2926
Form — Prime Health Complete (HMO SNP)
Last Updated: 12/23/2010

Medicare Part D Over-the-Counter List — H2416_H2926
Form — PrimeWest Senior Health Complete (HMO SNP)
Last Updated: 12/23/2010

Medication Reconciliation Tool — PW_022013_140R_04_13
Form — Pharmacy/Formulary
This tool is used by county case managers/home care agencies to complete medication reconciliation for the Quality Improvement Project (QIP).
Last Updated: 4/4/2013

Member Amendment Request Form — PW_2011_041
Form — Member
Request to access protected health information.
Last Updated: 4/19/2011

Member Appeal and Grievance Form — PW_2009_041
Form — Appeals & Grievances
Members or their Authorized Representatives should use this form to document and file Appeals or Grievances.
Last Updated: 1/22/2010

Member Inspection Form — PW_2011_376
Form — Member
Request to access protected health information
Last Updated: 4/19/2011

Member Transition of Care Notification — PW_2010_143/H2416_PW_2010_5143/H2926_PW_2010_5143
Form — County Case Managers
CCMs should use this form letter to notify members about the role of a CCM during a transition of care
Last Updated: 12/15/2011

Mental Health Targeted Case Management (MH-TCM) Notice of Action Form — PW_2010_215R_03_11
Form — County Case Managers
The Mental Health Targeted Case Management (MH-TCM) Notice of Action form is to be used when MH-TCM services are ending or being terminated. The reason services are ending or being terminated must be indicated on the form.
Last Updated: 3/22/2011

Mental Health Targeted Case Management (MH-TCM) Notice of Action Form — PW_2010_215R_03_11
Form — Mental Health
The Mental Health Targeted Case Management (MH-TCM) Notice of Action form is to be used when MH-TCM services are ending or being terminated. The reason services are ending or being terminated must be indicated on the form.
Last Updated: 3/22/2011

Mental Health Targeted Case Management (MH-TCM) Notice of Action Instructions — PW_2010_333
Form — County Case Managers
This policy should be followed by county case managers and their supervisors in all instances of case closure of MH-TCM services. It contains information about the correct documentation to include in case files and what to communicate to the PrimeWest Health Complex Care Coordinator.
Last Updated: 3/22/2011

Mental Health Targeted Case Management (MH-TCM) Notice of Action Instructions — PW_2010_333
Form — Mental Health
This policy should be followed by county case managers and their supervisors in all instances of case closure of MH-TCM services. It contains information about the correct documentation to include in case files and what to communicate to the PrimeWest Health Complex Care Coordinator.
Last Updated: 3/22/2011

MHCP Chiropractic Authorization Form — DHS-4878-ENG
Form — Service Authorizations
Chiropractors should use this form to provide clinical information when requesting additional visits (beyond 24 in a calendar year) for a PrimeWest Health member. Submit this form with a completed Medical Service Authorization Request Form.
Last Updated: 3/27/2013

MHCP Encounter Provider NPI/UMPI Notification/Request Form — PW_2009_093
Form — Contracting
This form is used to verify and register a provider with the State of Minnesota
Last Updated: 10/13/2011

MHCP Encounter Provider NPI/UMPI Notification/Request Form - Instructions — PW_2009_093I
Form — Contracting
Instructions for the MHCP Encounter Provider NPI/UMPI Notification/Request Form used to verify and register the provider with the State of Minnesota
Last Updated: 11/5/2010

MHCP Home Trial Log for Stander — PW_2008_208
Form — Service Authorizations
Providers should have members complete this form. The provider then submits it when requesting a Service Authorization for a Stander.
Last Updated: 1/22/2010

Minnesota Long Term Care Consultation Services Assessment Form — DHS-3428-ENG
Form — County Case Managers
Annual assessment completed by a qualified professional licensed social worker and/or public health nurse
Last Updated: 11/11/2011

Minnesota Uniform Credentialing Application (X14894): Initial, Dentist — PW_2011_086
Form — Credentialing
Providers should use this form to enroll a new dentist.
Last Updated: 4/13/2011

Minnesota Uniform Credentialing Application (X14894): Reappointment, Dentist — PW_2011_087
Form — Credentialing
Providers should use this form to enroll an existing dentist.
Last Updated: 4/13/2011

Minnesota Uniform Credentialing Application Initial: Physician/Allied Health Professional — PW_2011_088R_02_13
Form — Credentialing
Providers should use this form to enroll a new practitioner.
Last Updated: 4/17/2013

Minnesota Uniform Credentialing Application Reappointment: Physician/Allied Health Professional — PW_2011_089R_02_13
Form — Credentialing
Providers should use this form to enroll an existing practitioner.
Last Updated: 4/16/2013

Minnesota Uniform Formulary Exception Form — 6140_PW_FORM_1009
Form — Pharmacy/Formulary
Prescribers should use this form to request authorization for the use of a drug not included in our formulary.
Last Updated: 3/18/2010

Minnesota Uniform Practitioner Change Form — PW_012013_124
Form — Credentialing
Providers should use this form to add, remove, or make a change to demographic data for practitioners.
Last Updated: 3/29/2013

My Medicine Record — PW_022013_141
Form — Pharmacy/Formulary
This form helps members understand what medicines they should be taking as well as when and how to take them.
Last Updated: 3/4/2013

Network Information Request Form (NIR) — PW_2007_018R_02_11
Form — Contracting
Providers should use this form to submit demographic information for their facility during the PrimeWest Health contracting process.
Last Updated: 5/16/2011

Non-Contracted Provider Address Change — PW_2010_177R_03_13
Form — Claims
Non-contracted providers should use this form to request a change in a physical, mailing, or billing address. Contracted providers should call the Provider Contact Center at 1-866-431-0802 (toll free) to update addresses.
Last Updated: 3/29/2013

Non-participating Facility Births Evidence-based Childbirth Program — PW_2011_563
Form — Hospital
Providers performing deliveries at hospitals not on the DHS list of hospitals with approved policies must complete this form and include it as an attachment with each delivery claim.
Last Updated: 12/29/2011

Organizational Assessment Form — PW_2008_155R_06_11
Form — Contracting
Providers should use this form to submit information about their organization during the PrimeWest Health contracting/credentialing process.
Last Updated: 8/19/2011

Participation Request Form — PW_2008_254R_04_10
Form — Contracting
Providers who wish to contract with PrimeWest Health should complete this form.
Last Updated: 5/7/2010

Partners in Care Checklist — PW 2009 024R 02_11
Form — County Case Managers
A member letter encouraging members to receive a preventive visit. Members are encouraged to bring this letter with them to their health care provider visit.
Last Updated: 4/26/2011

Patient Health Questionnaire — PHQ_9
Form — Disease Management
The Patient Health Questionnaire (PHQ-9) is a nine-question survey used to determine the severity of depression for patients/members.
Last Updated: 4/20/2011

PCP notification of transition — PW_2010_137
Form — County Case Managers
This form is used by a county case manager (CCM) to notify a primary care provider of a transition of care due to hospitalization.
Last Updated: 2/7/2011

Personal Care Assistance (PCA) Agency — PW_2010_304_DHS_6005_ENG
Form — Contracting
Form for PCA providers to use when designating PCA billing staff. PrimeWest Health's version of DHS-6005-ENG.
Last Updated: 10/4/2010

Personal Care Assistant (PCA) Application — PW_2008_067R 09_12
Form — Credentialing
Submit this application if you are providing Personal Care Assistance services to a PrimeWest Health member.
Last Updated: 9/28/2012

Pharmacist Enrollment Application — PW_2007_011R_02_13
Form — Credentialing
Submit this form if you would like to become a credentialed pharmacist with PrimeWest Health.
Last Updated: 3/15/2013

Pharmacist Enrollment Application — PW_2007_011R_02_13
Form — Pharmacy/Formulary
Submit this form if you would like to become a credentialed pharmacist with PrimeWest Health.
Last Updated: 3/15/2013

Pharmacist Reappointment Enrollment Application — PW_012013_126
Form — Credentialing
Providers should use this form to recredential existing contracted pharmacists at a Medication Therapy Management (MTM) services pharmacy.
Last Updated: 3/15/2013

Pharmacist Reappointment Enrollment Application — PW_012013_126
Form — Pharmacy/Formulary
Providers should use this form to recredential existing contracted pharmacists at a Medication Therapy Management (MTM) services pharmacy.
Last Updated: 3/15/2013

PrimeWest Health Authorization to Use or Disclose Protected Health Information (PHI) — PW_2012_008/H2416_PW_2012_5008/H2926_PW_2012_5008
Form — Member
Members should use this form to authorize an entity or person to use or disclose Protected Health Information (PHI) to an entity/person other than the member.
Last Updated: 3/29/2012

Private Room Request Form — PW_2011_487
Form — Long-term Care
Use this form to explain a member’s diagnoses, medical conditions, or other circumstances that create the need for a private room
Last Updated: 2/8/2013

Provider Appeal Form — PW_2008_050R_04_10
Form — Appeals & Grievances
Providers should use this form to submit an Appeal to PrimeWest Health.
Last Updated: 5/17/2010

Provider Assessment Notification — PW_2011_485
Form — County Case Managers
County case managers use this form to notify a primary care provider that the interdisciplinary care team has scheduled a reassessment and is requesting the provider’s input.
Last Updated: 11/18/2011

Reappointment Credentialing Application for Fitness Professionals — PF_2011_001R_02_13
Form — Credentialing
Providers should use this form to recredential existing contracted fitness professionals.
Last Updated: 3/29/2013

Request for Medicare Prescription Drug Coverage Determination Form — H2416_PW_2012_1019
Form — PrimeWest Senior Health Complete (HMO SNP)
Universal request for prescription drug coverage determination form provided by CMS.
Last Updated: 1/3/2012

Request for Medicare Prescription Drug Coverage Determination Form — H2926_PW_2012_3019
Form — Prime Health Complete (HMO SNP)
Universal request for prescription drug coverage determination form provided by CMS.
Last Updated: 1/3/2012

Request for Payment of Long-Term Care Services — DHS-3543-ENG
Form — PrimeWest Senior Health Complete (HMO SNP)
Members should complete this form and submit it to PrimeWest Health to request payment for long-term care services.
Last Updated: 12/12/2011

Request for Redetermination of Medicare Prescription Drug Denial — H2926_PW_2012_3018
Form — PrimeWest Senior Health Complete (HMO SNP)
Universal form from CMS for members asking for a redetermination of a drug denial
Last Updated: 1/3/2012

Request for Redetermination of Medicare Prescription Drug Denial — H2926_PW_2012_3018
Form — Prime Health Complete (HMO SNP)
Universal form from CMS for members asking for a redetermination of a drug denial
Last Updated: 1/3/2012

Restricted Recipient Program (RRP) Referral Form — PW_2012_244
Form — Service Authorizations
Please complete this Service Authorization form for PrimeWest Health members.
Last Updated: 6/7/2012

Service Authorization - Inpatient Admission Authorization Request — PW_2008_092R_04_13
Form — Service Authorizations
Providers should use this form to submit a request for coverage for an inpatient admission.
Last Updated: 4/25/2013

Service Authorization - Medical — PW_2006_080R_04_13
Form — Service Authorizations
Providers should use this form to submit a request for coverage for a medical service/device.
Last Updated: 4/25/2013

Skilled Nursing Facility (SNF) Comprehensive Assessment Tool - Part 1 — PW_2010_165aR_1_11
Form — County Case Managers
County case managers should complete and submit this form to PrimeWest Health when a member is admitted to a Skilled Nursing Facility and annually thereafter. It should also be re-submitted when there is a significant change in a member's plan of care.
Last Updated: 1/14/2011

Skilled Nursing Facility (SNF) Comprehensive Assessment Tool - Part 2 — PW_2010_165b
Form — County Case Managers
County case managers should complete this form when a member is admitted to a Skilled Nursing Facility, annually, and for any significant plan of care changes.
Last Updated: 2/7/2011

Skilled Nursing Facility (SNF) Notification Form for SNBC and MSHO — PW_2007_112
Form — County Case Managers
Skilled Nursing Facilities should complete and submit this form to PrimeWest Health when admitting a member with PrimeWest Senior Health Complete (our MSHO plan) or Prime Health Complete (our SNBC plan). This form is used to verify claims.
Last Updated: 12/12/2012

Skilled Nursing Facility (SNF) Notification Form for SNBC and MSHO — PW_2007_112
Form — Prime Health Complete (HMO SNP)
Skilled Nursing Facilities should complete and submit this form to PrimeWest Health when admitting a member with PrimeWest Senior Health Complete (our MSHO plan) or Prime Health Complete (our SNBC plan). This form is used to verify claims.
Last Updated: 12/12/2012

Skilled Nursing Facility (SNF) Notification Form for SNBC and MSHO — PW_2007_112
Form — PrimeWest Senior Health Complete (HMO SNP)
Skilled Nursing Facilities should complete and submit this form to PrimeWest Health when admitting a member with PrimeWest Senior Health Complete (our MSHO plan) or Prime Health Complete (our SNBC plan). This form is used to verify claims.
Last Updated: 12/12/2012

SNBC Initial Communication/Renewal Form — H2926_PW_3078
Form — County Case Managers
County case managers should use this form to communicate initial, renewal, or change in services.
Last Updated: 1/22/2010

SNF MDS Risk Summary Form — PW_2007_064R12_10
Form — County Case Managers
Nursing facilities should complete and submit this form to PrimeWest Health; it is used to assess a member's condition.
Last Updated: 1/4/2013

SNF MDS Risk Summary Form — PW_2007_064R12_10
Form — Prime Health Complete (HMO SNP)
Nursing facilities should complete and submit this form to PrimeWest Health; it is used to assess a member's condition.
Last Updated: 1/4/2013

SNF MDS Risk Summary Form — PW_2007_064R12_10
Form — PrimeWest Senior Health Complete (HMO SNP)
Nursing facilities should complete and submit this form to PrimeWest Health; it is used to assess a member's condition.
Last Updated: 1/4/2013

Special Needs BasicCare (SNBC) Care Plan — PW_2011_513
Form — County Case Managers
Care plan for members enrolled in Special Needs BasicCare (SNBC)
Last Updated: 8/6/2012

Special Needs BasicCare (SNBC) Care Plan Summary — PW_2012_124
Form — County Case Managers
Care plan summary for members enrolled in Special Needs BasicCare (SNBC)
Last Updated: 8/6/2012

Supplemental Sports Exam Form — WEB_052013_013
Form — Maternal Child Health
This is a form from the Minnesota State High School League with the supplemental elements to turn a school sports physical into a complete child and teen checkup (C&TC).
Last Updated: 5/8/2013

Synagis® Palivizumab Respiratory Syncytial Virus (RSV) Prophylaxis — PW_2010_306R_12_10
Form — Service Authorizations
A form for providers to use to request synagis and document medical information necessary to make medical necessity determination
Last Updated: 12/17/2010

Targeted Case Management (MH-TCM) Service Authorization Request Form — PW_2009_277R_12_10
Form — Service Authorizations
Providers should use this form to submit a request for coverage for Targeted Case Management (MH-TCM).
Last Updated: 10/22/2012

Transition of Care Instructions — PW_2010_124R_04_13
Form — County Case Managers
County case managers should use these instructions to complete the Transition of Care Update Form (PW_2009_215).
Last Updated: 4/25/2013

Transition of Care Instructions — PW_2010_124R_04_13
Form — Prime Health Complete (HMO SNP)
County case managers should use these instructions to complete the Transition of Care Update Form (PW_2009_215).
Last Updated: 4/25/2013

Transition of Care Instructions — PW_2010_124R_04_13
Form — PrimeWest Senior Health Complete (HMO SNP)
County case managers should use these instructions to complete the Transition of Care Update Form (PW_2009_215).
Last Updated: 4/25/2013

Transition of Care Update Form — PW_2009_215
Form — County Case Managers
County case managers should complete and submit this form to notify PrimeWest Health when a member transfers from one facility to another; transfers include hospital admissions, hospital discharges, SNF admissions, and SNF discharges.
Last Updated: 2/27/2013

Transition of Care Update Form — PW_2009_215
Form — Prime Health Complete (HMO SNP)
County case managers should complete and submit this form to notify PrimeWest Health when a member transfers from one facility to another; transfers include hospital admissions, hospital discharges, SNF admissions, and SNF discharges.
Last Updated: 2/27/2013

Transition of Care Update Form — PW_2009_215
Form — PrimeWest Senior Health Complete (HMO SNP)
County case managers should complete and submit this form to notify PrimeWest Health when a member transfers from one facility to another; transfers include hospital admissions, hospital discharges, SNF admissions, and SNF discharges.
Last Updated: 2/27/2013

Waiver of Liability Statement — PW_2012_359
Form — Appeals & Grievances
A non-contracted provider wishing to file a standard Appeal for a denied claim should fill out this form.
Last Updated: 7/31/2012

Web Portal Registration Form — PW_2009_108
Form — Claims
Providers should use this form to register for the Provider Web Portal.
Last Updated: 1/22/2010

Web Portal Registration Form — PW_2009_108
Form — Service Authorizations
Providers should use this form to register for the Provider Web Portal.
Last Updated: 1/22/2010

Web Service Connection Form — PW_042013_266
Form — Claims
Providers should use this form to sign up for a connection to PrimeWest Health's web service. The connection will allow providers to check PrimeWest Health member eligibility and claim status.
Last Updated: 4/9/2013