If you are a new provider to PrimeWest Health—meaning that you are not participating in our network—and need to submit a claim or payment request for health care services or supplies, you must submit the following forms for provider setup before we can process your claims:

• Provider NPI/UMPI Notification Request
• Request for Taxpayer Identification Number and Certification

In compliance with Internal Revenue Service (IRS) regulations, PrimeWest Health is requesting that you provide a completed W-9 form and, as a Managed Care Organization (MCO) contracted with the Minnesota Department of Human Services (DHS) to administer health care benefits, we are required to submit certain provider information to the State. Failure to provide a W-9 form and the Provider NPI/UMPI Notification Request form will result in the denial of your claims.

Please return both forms even if you are exempt from backup withholding. Please make sure you complete both forms in their entirety and in accordance with the instructions. The forms must be completed in a legible manner and should contain accurate and current information.

The Provider NPI/UMPI Notification Request form is required for each rendering provider submitted on claims. A Social Security Number (SSN) is required and will only be shared with the State of Minnesota for reporting purposes.

Please pay particular attention to the following for the W-9 form:

• Individual Taxpayer Identification Number (TIN)
• When including a SSN: Only the name of the person whose SSN is included should be entered on the first line. Include the last name, first name, and middle initial; OR
• When including an Employer Identification Number (EIN): The name of the partnership, corporation, sole proprietorship, club, or other entity must be entered on the first line exactly as it was registered with the IRS when the Federal EIN was assigned.

Please do not submit a TIN that has not been assigned to your name. For example, a health care provider who submits his/her name on a W-9 must use his/her own SSN. If a health care provider uses the clinic name, then the W-9 must contain the Federal EIN of the clinic.

Only one TIN can be submitted on the form. Do not list both an SSN and an EIN.

Please return the completed forms by fax to 1-320-762-1805 or by mail to:

Claims Department – Accounts Payable Coordinator
PrimeWest Health
2209 Jefferson St, Ste 101
Alexandria, MN 56308