The Health Information Technology page on the Minnesota Department of Health website offers resources for providers interested in Electronic Health Records.

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2009 Minnesota Session Law Chapter 79, Article 5, Section 13 indicates that the State will no longer pay for services related to a hospital-acquired condition. Effective with claims submitted on or after August 25, 2010, PrimeWest Health will be adopting this Minnesota Health Care Programs (MHCP) guideline and will require the present on admission (POA) indicator on all inpatient claims for all hospital provider types (Acute Care and Critical Access). We will use this indicator to identify services related to a hospital-acquired condition.

Claims for hospital-acquired conditions indicated by the following ICD-9-CM diagnosis codes and designated as a complicating or major complicating condition will be denied (subject to change as updates to ICD-9-CM and/or ICD-10-CM occur):

• 998.4 or 998.7
• 999.1
• 999.6
• 707.23 or 707.24
• 800 – 829, 830 – 839, 850 – 854, 925 – 929, 940 – 949, 991 – 994 (CC or MCC codes only)
• 996.64
• 999.31
• 249.10, 249.11, 249.20, 249.21, 250.10 – 250.13, 250.20 – 250.23, 251.0
• 996.67 or 998.59 with presence of ICD-9-CM procedure codes 81.01 – 81.08, 81.23, 81.24, 81.31 – 81.38, 81.83, or 81.85
• 998.59 with presence of ICD-9-CM procedure codes 44.38, 44.39, or 44.95
• 519.2 with presence of ICD-9-CM procedure codes 36.10 – 36.19
• 453.40 – 453.42, 415.11, or 415.91 following ICD-9-CM procedure codes 00.85 – 00.87 or 81.51 – 81.52

Per Minnesota Law, you are not to bill the recipient for any payment disallowed due to this ruling.

If you have any questions regarding this requirement, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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Effective August 15, 2010, PrimeWest Health will require Service Authorization for the following procedures:

• Breast MRI
  Breast MRI procedure codes that will require authorization include: 0159T, 77021, 77058, 77059, C8903, C8904, C8905, C8906, C8907, and C8908.
  
  Prime West Health will use Minnesota Department of Human Services (DHS) criteria to determine medical necessity.

• Spinal Fusion
  Spinal fusion procedure codes that will require authorization include: 22532, 22533, 22534, 22548, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22800, 22802, 22804, 22808, 22810, and 22812.
  
  PrimeWest Health will follow DHS criteria for lumbar spinal fusion. InterQual criteria will be used for cervical and thoracic spinal fusion.

If you have questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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For Medicaid-only members, hospitals are required to follow Minnesota Health Care Programs (MHCP) guidelines and submit claims to PrimeWest Health in the same manner they would submit them to the Minnesota Department of Human Services (DHS). For members on a PrimeWest Health Medicare program or members who have Medicare as their primary insurance, claims should be submitted to PrimeWest Health following Centers for Medicare & Medicaid Services (CMS) guidelines and should be billed exactly as they are to Medicare.

The billing requirements outlined below are effective for all inpatient claims submitted on or after August 1, 2010.

Billing for members enrolled in PrimeWest Health Medicare-based programs or members who have Medicare as their primary insurance

• Bill separately (multiple claims) for hospital, specialty unit, and mental health unit.
• Use the hospital NPI for acute hospital claim(s) and the specialty unit NPI or mental health unit NPI for specific unit claim(s). This will ensure the correct Medicare/Online Survey, Certification, and Reporting (OSCAR) number is used.
  

Billing for Medicaid-only PrimeWest Health members

• Bill one claim, regardless if transfers are involved between units (e.g., combine hospital claim[s] and mental health unit claim[s]) or if inpatient stay is within a specialty unit for the entire length of stay.
• Use the hospital NPI only. Do not separate claims out by unit NPI. Do not use any specialty unit NPIs that your facility may have.
  

Please continue to notify PrimeWest Health Utilization Management of all inpatient hospital admissions.

• Phone: 1-866-431-0803 (toll free)
• Fax: 1-866-431-0804 (toll free)

If you have questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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Electronic Data Interchange (EDI) 835 Electronic Remittance Advice (835) is available and can be requested through our Provider Contact Center or by filling out the Electronic Remittance Advice (835) Registration Form for 837 Institutional/Professional (837 I/P) Claims. You may also need to contact your billing software vendor and clearinghouse vendor to complete set up.

PrimeWest Health has an option for providers to retrieve our electronic remittance advices from a secure file transfer portal (SFTP). If you would like to use PrimeWest Health’s SFTP site for retrieval, please check “SFTP” in the Clearinghouse section of the Electronic Remittance Advice (835) Registration Form for 837 Institutional/Professional (837 I/P) Claims. Once registered, a PrimeWest Health representative will contact you with information for downloading from the site.

You can use the You can use the Medicare Remit Easy Print (MREP) software to view and print your electronic remittance advices downloaded from the SFTP site.

All providers also have the option to view their own remittance advices on the PrimeWest Health Provider Web Portal. To use the Web Portal, you must first complete the Web Portal Registration Form. Once registered, you will be provided with a user name and password.

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The 2010 Minnesota Legislature authorized a 5 percent rate reduction effective July 1, 2010, for Customized Living (CL) and 24-hour Customized Living (24 CL) service rate limits, component rates, and authorizations provided under the Elderly Waiver (EW) program.

The legislation mandates that, effective July 1, 2010, all Managed Care Organizations (MCOs) must ensure that rates paid do not exceed the rate limits and component rates published in the Minnesota Department of Human Services' (DHS) bulletin (#10-25-04). Accordingly, effective July 1, 2010, PrimeWest Health is required to reduce all authorized CL rates by 5 percent.

PrimeWest Health will amend the rating process to implement the reduction on members' CL services. New service agreements indicating the reduced rate for all PrimeWest Health members will be sent to providers near the end of July.

Claims with a date of service of July 1, 2010, and later should be submitted with the new rate. Claims submitted with rates that don't match the updated service agreements will be denied.

If you have questions regarding this update, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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PrimeWest Health requires notification from hospitals of all hospital admissions, including obstetric (OB) deliveries. Previously, following notification, your hospital's Utilization Management/Utilization Review (UM/UR) department received a phone call from PrimeWest Health with a Service Authorization number for the hospital stay (followed by a written authorization letter). This process will be changing for uncomplicated OB delivery notifications only.

Effective June 21, 2010, PrimeWest Health will no longer be providing a Service Authorization number for uncomplicated OB deliveries (normal vaginal deliveries [NVDs] and C-sections). A Service Authorization number will no longer be required on claims you submit to PrimeWest Health for these services.

Even though a Service Authorization number will no longer be required on claims, you still need to notify PrimeWest Health when a member has been admitted to deliver a baby. The notification must include the following:

• Mother's name, DOB, and PMI number
• Infant's DOB and gender

Failure to notify PrimeWest Health with the above information following a delivery will result in delayed claims payment.

The newborn's hospital stay has not, and will not, need a Service Authorization unless the baby's hospital stay exceeds the mother's stay (i.e., the baby has complications requiring an extended nursery stay). In these instances, a Service Authorization for the baby's nursery stay will be required. PrimeWest Health will continue to require supporting medical information in order to make authorization determinations for the baby's stay.

For more information about inpatient hospital authorizations, please see Chapter 13 of the PrimeWest Health Provider Manual.

If you have questions about this notice, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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Please see the Centers for Medicare & Medicaid Services' (CMS) Medicare Learning Network (MLN) article MM6821 for information on submitting informational only inpatient claims for Medicare Advantage beneficiaries.

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The Medicare Learning Network (MLN) Matters article number MM6777 posted by the Centers for Medicare & Medicaid Services (CMS) applies to the following provider types paid under their respective Prospective Payment Systems (PPSs) and submitting claims to Medicare contractors (Fiscal Intermediaries [FIs] and/or Part A/B Medicare Administrative Contractors [A/B MACs]) for services provided to Medicare beneficiaries:

• Long-Term Care Hospitals (LTCHs)
• Inpatient Psychiatric Facilities (IPFs)
• Inpatient Rehabilitation Facilities (IRFs)

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Effective July 26, 2010, PrimeWest Health will follow the Minnesota Department of Human Services (DHS) requirement that independent pathologists who bill for the professional component of laboratory services:

• Indicate the hospital's or independent laboratory's National Provider Identifier (NPI) as the rendering provider
• Enter modifier 26 and modifier 90 in the modifier field
• If modifier 90 is used, the system will look at the rendering provider field for Clinical Laboratory Improvement Amendment (CLIA) number certification
• Do not use CLIA numbers on claims

You can find additional details on billing requirements for independent pathologists and laboratory services in chapter 11 of the Provider Manual.

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Effective July 26, 2010, when submitting the Client Placement Authorization (CPA) form (DHS-2780-ENG) to PrimeWest Health for authorization of chemical dependency treatment, you must also send the Rule 25 Assessment and Placement Summary (DHS-2794-ENG).

Please note the following:

• Each dimension on the rationale page (page 2) of the Rule 25 Assessment and Placement Summary must be a brief summary taken from the Rule 25 Assessment Tool
• When an update to a CPA form is submitted, you must also make appropriate updates on the Rule 25 Assessment and Placement Summary
• The Rule 25 Assessment and Placement Summary must accompany the CPA form each time the CPA form is submitted to PrimeWest Health
• If you choose to submit the full Rule 25 Assessment Tool, you will not be required to submit the Rule 25 Assessment and Placement Summary
  

You can locate the most current version of the Rule 25 Assessment and Placement Summary at http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-2794-ENG.

If you have questions about this new requirement, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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Please see the Minnesota Department of Health (MDH) bulletin 10-04 MHC-51 for updated information on submission of Outcome and Assessment Information Set (OASIS) assessments to the Centers for Medicare & Medicaid Services (CMS) OASIS State system.

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Effective July 15, 2010, PrimeWest Health will be following Minnesota Department of Human Services (DHS) guidelines for Service Authorization requirements for diagnostic assessment, explanation of findings, and neuropsych testing. These requirements are as follows:

• Diagnostic assessment (90801, 90802): Service Authorization needed for more than four sessions in a year
• Explanation of findings (90887): Service Authorization needed for more than two sessions in a year
• Neuropsych testing (96118, 96119, 96120): Service Authorization needed for a cumulative of more than seven hours of neuropsychological testing in a year. For these codes, one unit is one hour.

Service Authorization requests should be faxed to the PrimeWest Health Utilization Management department at 1-866-431-0804 (toll free).

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In July of 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) was enacted. MIPPA placed new requirements on Special Needs Plans (SNPs), one of which is the transition of care requirement. Transition of care is defined as the movement of a member from one care setting to another as the member's health status changes. According to the third edition of Case Management: a Practical Guide for Education and Practice, transition of care is "the process of moving a member from one level of care to another. Another way of looking at transition of care is the act of handing off the responsibility for a member's care from one provider to another, from one care setting to another or from one level of care to another."
The purpose of the MIPPA requirement is to help better manage member transitions and prevent unplanned transitions. The National Committee for Quality Assurance (NCQA) also requires SNPs to have policies and procedures in place for transition of care. Some examples of transition of care situations are the following:

• Home to Hospital
• Hospital to Skilled Nursing Facility (SNF)
• Hospital to Swing Bed
• Home to Emergency Room (ER)
• Home to Customized Living
• SNF to Home
• Home to Inpatient Mental Health Facility

During a transition of care, the county case manager is responsible for the following:

• Providing consistent support to the member throughout the transition
• Identifying planned and unplanned transitions
• Communicating with the facility, providers, members, and/or responsible party about the transition process and changes in the member's health status and care needs
• Reaching out to the member after his/her return to the usual setting of care to prevent readmission or ER visits. This includes the following:
• Reviewing medication changes and making sure new prescriptions are filled
• Helping the member with durable medical equipment supplies
• Helping the member with follow-up appointments and transportation
• Understanding changes in the member's functional needs
• Increasing member knowledge and understanding of the disease process

The county case manager is also responsible for the following communications with the primary care provider and facility:

• Ensuring that all necessary information is provided to pertinent parties within one business day to make the transition as successful as possible
• Contacting the primary care provider/clinic to notify staff of the admission (if not involved in the admission); contacting the receiving facility
• Contacting the discharge planner to share what services are currently being provided and who is providing the services

The overall goal of the transition of care process is to reduce instances of fragmented or unsafe care and to reduce unnecessary readmissions. We hope that this process will assure that plan of care/transfer/discharge instructions are followed when members are transferred or discharged. If you have questions, contact Becki Pender, RN, CCP, Senior Care Manager at 1-320-335-5204, 1-888-588-4420 ext. 5204 (toll free), or becki.pender@primewest.org; or Elaine Carlquist, BSN, PHN, CCP, EW Senior Care Coordinator, at 1-320-335-5354, 1-888-588-4420 ext. 5354 (toll free), or elaine.carlquist@primewest.org; or Jennifer Bundy, RN, BSN, PHN, CCP Disability Care Coordinator at 1-320-335-5351, 1-888-588-4420 ext. 4420 (toll free), or jennifer.bundy@primewest.org.

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To view the latest Minnesota Department of Human Services (DHS) provider update on customized living (CL), please go to the DHS website and view provider update # 10-25-03.

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Authorization requirements for TENS (Transcutaneous Electrical Nerve Stimulator) Units are changing. Effective July 1, 2010, PrimeWest Health will require Service Authorizations for the purchase or rental of all TENS units. Service Authorization decisions are based on medical necessity. TENS Units are not medically necessary for the treatment of chronic low back pain, defined as low back pain from any cause lasting six weeks or more.

This change in authorization requirements is being made to align PrimeWest Health more closely with the Minnesota Department of Human Services' (DHS) authorization requirements. Please refer to the PrimeWest Health Provider Manual for more information.

Service Authorization requests should be faxed to PrimeWest Health's Utilization Management department at 1-866-431-0804 (toll free).

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For quality purposes, PrimeWest Health continually monitors the volume of calls to our Provider Contact Center. Findings indicate that there are more calls in the morning than late afternoon. To better serve you, effective June 1, 2010, the Provider Contact Center hours will be Monday - Friday, 8 a.m. - 4:30 p.m. This change will allow us to provide additional coverage during peak times. The Provider Contact Center number is 1-866-431-0802 (toll free).

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As part of the E3 initiative, PrimeWest Health is working toward reducing paper transactions. As a result, PrimeWest Health is only accepting provider Appeals that are sent via fax.

Please submit all Appeals to PrimeWest Health via fax to 1-320-335-5285. Appeals will not be considered unless they are submitted via fax. Your fax will be processed entirely on an electronic basis.

Thank you in advance for your cooperation. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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