A Model of Care summary presentation is available on our website. This presentation is a summary of the PrimeWest Health Model of Care for our Special Needs Plan (SNP) members and provides a general overview of the Model of Care.

PW_2012_068

PrimeWest Health is posting this information to provide clarification on our Timely Filing Limit for claim submission. No changes have been made to the requirements.

Claims for any service provided to PrimeWest Health members must be submitted correctly and received by PrimeWest Health no later than 180 days from the date of services. Medicare and third party liability (TPL) claims must be received within 180 days from the date of the primary or secondary insurance remittance advice.

Claims that are received beyond the 180-day filing limit will be denied with "Filing Limit Exceeded."

You can see complete billing guidelines in Chapter 4, Billing Policy, of the Provider Manual.

PW_2012_064

In an effort to ensure accurate claims payment and minimize reprocessing, claims that are subject to member cost sharing in the form of a copay and/or deductible, as required by the State, may be delayed due to the coordination of cost sharing amounts between medical and pharmacy claims. Once a member has reached his/her maximum cap or all claims subject to cost sharing have been received for the month, the claims will be released for payment within the 30 business day processing guidelines.

Implementation of cost sharing, which can include copays and/or deductibles, is part of the 2011 Minnesota Legislative session. You can find more information on cost sharing requirements in Chapter 9, Article 6, Sections 49 – 51 and 71 of the 2011 Minnesota Session Laws, 1st Special Session.

While you may experience delays in receiving payment on claims, it is PrimeWest Health’s goal to minimize claim adjustments due to coordination of copays and the limits between our medical and pharmacy processing systems. The benefit to providers is a less volatile claims process, with fewer claims needing to be reprocessed multiple times.

You can view the status of submitted claims through the PrimeWest Health provider web portal. If you have not yet registered for the portal, you can register on our website.

We apologize for any delays you may experience and appreciate your patience while we work to ensure your claims are processed accurately.

PW_2012_061

Effective February 1, 2012,PrimeWest Health is adjusting the amount we pay for negotiated-rate medical equipment and supplies in order to more closely align with Minnesota Department of Human Services (DHS) pricing of these items, which will be based on the rate methodology available on February 1, 2012. You can view pricing details for equipment and supplies that do not have reimbursement rates published in the DHS fee schedule on the DHS website. Scroll down to the section titled "Equipment and Supplies" for this information.

This change is a result of provider feedback received at a recent Durable Medical Equipment (DME) provider workgroup meeting held at DHS.

PW_2012_058

The Aging and Adult Services Division of the Minnesota Department of Human Services (DHS) is seeking proposals from qualified responders for State fiscal year 2013, July 1, 2012 – June 30, 2013, to expand and integrate Home and Community Based Services (HCBS) for older adults that allow local communities to rebalance their long–term care service delivery system, support people in their own homes, expand the caregiver support and respite care network, and promote independence, as directed by MN Stat. secs. 256.9754 and 256B.0917, subds.6 and 13, as posted in the January 3, 2012, issue of the Minnesota State Register.

The complete request for proposal (RFP) and application, including directions, is available on the CS/SD Applicant’s web page, which you can access through DHS Community Service/Community Services Development Grants web page. 

An optional Responders Webinar will be held Tuesday, January 31, 2012, 9a.m., Central Standard Time. Responders interested in attending must register online through the DHS iLinc Public Page – Open Sessions.

For more information, contact Jacqueline Peichel, Community Program and Policy Consultant, at 1-651-431-2583 or jacqueline.s.peichel@state.mn.us. Ms. Peichel is the only person designed to answer questions or inquiries regarding this RFP.

PW_2011_040

Effective January 1, 2012, the names of oral interpreters will be required on all claims submitted to PrimeWest Health for reimbursement of oral interpretation services. This is a change from the previous requirement, which stated only that names be noted in the medical record. All oral interpreters must be registered and approved through the Minnesota Department of Health (MDH) to provide services to PrimeWest Health members. Please refer to the MDH Registry List for the list of approved oral interpreters.

The SV1 segment, element SV101-7 of the 5010 claim format, which becomes effective January 1, 2012, is designated for the inclusion of the interpreter name. Upon claim submission to PrimeWest Health, the interpreter listed on the claim will be validated against the MDH Registry List.

Effective January 1, 2012, claims submitted without the interpreter name in the correct field or with the name of an interpreter that does not appear on the MDH Registry List will be denied.

For additional information on oral interpreter services, please see Chapter 1, Requirements for Providers, of the PrimeWest Health Provider Manual.

PW_2011_334

The Winter 2011 issue of PrimePointers has been sent out electronically to subscribers and is available online! If you are not receiving PrimePointers electronically, sign up today! If you already subscribe to our provider email notifications and would like to add a PrimePointers subscription, you can open any of our provider email notifications, click update subscription preferences at the bottom of the email, select PrimePointers under "Subscribe to our publications," and click Update Profile.

Electronic PrimePointers is an additional way to stay in touch with PrimeWest Health. This provider publication keeps you up-to-date on topics important to you in an easy-to-use electronic format!

PrimePointers:

• Provides you with up-to-date information on claims and coding requirements
• Informs you about State and Federal regulations
• Lets you know about PrimeWest Health program changes and updates
• Serves as a supplement to Provider Updates posted on the PrimeWest Health website

Electronic delivery:

• Allows everyone in your office to have his/her own copy—no more waiting for it to make the rounds
• Lets you quickly identify articles by type (Business Office, Contracting & Credentialing, and Medical) so you can skip to only those articles that interest you
• Allows you to search by keyword, author, subject, etc.
• Makes it easier to store and archive past issues

In response to the 2011 Minnesota Legislative session amending MN Stat sec. 256B.0625, for items or services provided on or after January 1, 2012, the Minnesota Department of Human Services (DHS) requires that Medicare crossover claims be processed in the same manner as commercial crossover claims. Through 2011, PrimeWest Health and DHS fee-for-service automatically covered and paid Medicare coinsurance and deductibles. However, the new coordination of benefits (COB) rules require the following processing logic:

1. PrimeWest Health will compare DHS (Medical Assistance [MA]) allowable (net of legislative adjustments) to Medicare PAID amount
2. Does MA rate exceed Medicare PAID amount?
1. If NO, PrimeWest Health will not make an additional payment
2. If YES, PrimeWest Health will pay the difference up to the Medicare allowable

If a provider contract indicates an MA allowable greater than 100 percent of MA, that amount (net of legislative adjustments) will be used for comparison purposes.

For members who have both Medicare and Medicaid (PrimeWest Senior Health Complete [HMO SNP] and Prime Health Complete [HMO SNP]), PrimeWest Health will combine our Medicare and Medicaid payment through our claims process. We will compare the net Medicare PAID amount (by us) to the Medicaid ALLOWED amount to determine if additional payment is to be made above and beyond the Medicare level of payment.

Inpatient diagnosis-related group (DRG) facility, mental health services, and end-stage renal disease (ESRD) services are exempt from this requirement and payment will be processed according to the current rules in which copays and deductibles are covered.

EXAMPLES
The examples show the calculation process for Minnesota Senior Care Plus (MSC+) members with Medicare only. Payment for members with both Medicare and Medicaid follows the same principle, as explained above.
* = net of legislative adjustments

Example 1:
Billed amount = 100
Medicare Allowable = $80
Medicare PAID = $64
MA *allowable = $70

PrimeWest Health would pay $6 ($70 MA allowable less $64 Medicare PAID)

Example 2:
Billed amount = 100
Medicare Allowable = $80
Medicare PAID = $64
MA *allowable = $60

PrimeWest Health would pay $0 (MA allowable is less than Medicare PAID)

Example 3:
Billed amount = 100
Medicare Allowable = $80
Medicare PAID = $64
Medicare Coinsurance = $16
MA *allowable = $85

PrimeWest Health would pay $16 (paying the difference between $85 MA allowable and $64 Medicare PAID, up to the $16 coinsurance amount).

PW_2011_568

This update contains supplemental information to the letter PrimeWest Health sent to providers on November 28, 2011.

The Minnesota Department of Human Services (DHS) recently posted an update (MHP-11-12) on the Evidence-Based Childbirth Program. This update provides additional details for hospitals that are required to submit their policies to DHS for approval and information about the process required by physicians submitting claims for deliveries performed in a hospital that does not have approved policies on file at DHS.

The Evidence Based Childbirth Program is a result of a new Minnesota law (MN Stat. sec. 256B.0625, subd.3g) that goes into effect January 1, 2012. This law requires hospitals to implement policies and processes to reduce the number of elective inductions of labor prior to 39 weeks' gestation for recipients of Minnesota Health Care Programs (MHCP), including Medical Assistance (MA) and MinnesotaCare members. PrimeWest Health is required to ensure our contracted hospitals follow this law.

Via MN-ITS, DHS is posting the list of hospitals that have submitted their policies for approval. PrimeWest Health encourages providers that perform delivery services to review this list. Providers performing deliveries at hospitals not on the list must complete the Non-Participating Facility Births Evidence-Based Childbirth Programs form and include the form as an attachment with each delivery claim.

As part of MN Stat. sec. 144.0724 enacted by the 2011 Minnesota Legislative session, effective January 1, 2012, resident resource utilization group (RUG) reimbursement classifications will be established according to the 48 group, RUG-IV model. (Prior to January 1, 2012, resident reimbursement classifications were established according to the 34 group, version III or RUG-III model).

To help ensure appropriate reimbursement, please submit revised Skilled Nursing Facility (SNF) Notification Forms with the updated RUG information for PrimeWest Health members by January 17, 2012. Fax revised forms to Utilization Management at 1-866-431-0804 (toll free).

PW_2011_560

In October 2011, PrimeWest Health posted an update regarding the new code for Provenge^® (Q2043). The Centers for Medicare & Medicaid Services (CMS) recently revised the MedLearn article MM7431 to clarify that a separate payment for the cost of administration is allowed when billing for this drug. As a reminder, Provenge^® requires a Service Authorization.

PW_2011_566

2011 legislation amended MN Stat. secs. 256B.0631 and 256L.03 to implement Minnesota Health Care Program (MHCP) member cost sharing in the form of copays and deductibles.

Services provided to members in the Prepaid Medical Assistance Program (PMAP), MinnesotaCare, or Minnesota Senior Care Plus (MSC+) on or after January 1, 2012, may have copays and/or deductibles applied. The following members are excluded from this cost sharing obligation:

• Children under 21
• Pregnant women
• Members residing or expected to reside more than 30 days in medical institutions, including hospitals and nursing homes
• Members on hospice care
• Members who receive emergency services provided in a hospital, clinic, office, or other facility
• Members who receive family planning services
• Dually eligible members who receive services paid for by Medicare
• Members who receive chemical dependency treatment services pursuant to MN Stat. sec. 254B.03, subd. 2
  

For all other members, cost sharing will be applied to most services within the member's benefit set, unless the service itself is excluded.

Included in the legislation is a cost sharing cap for members. The cost sharing cap is a maximum monthly out-of-pocket limit. All cost sharing (copays and deductibles) must not exceed the cost sharing cap. This amount will vary by member, as cost sharing is capped at 5 percent of the member's income.

There are many variables in the application of copays and deductibles, and providers will not be able to appropriately determine a copay or deductible amount until after their claim is processed. Since there is not real-time claims adjudication for most providers, the cost sharing amount might change even if you were able to determine the cost sharing amount at the time of service.

As a provider, you will need to collect the appropriate copay or deductible from the member when you know the amount. Because determining the correct cost sharing amount is difficult, PrimeWest Health encourages providers to hold off on collecting any cost sharing from the member until after your claim is processed and you receive an Explanation of Payment (EOP) noting the member responsibility.

PrimeWest Health provides education to our members about their responsibility for paying any cost sharing for the services they incur. You may not deny services to members who are unable to pay their cost sharing.

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

PW_2011_026

PrimeWest Health's Dental Lunch & Learn was a great success! If you were unable to attend or would like to review any of the information presented, please take a moment to review our PowerPoint presentation. If you have any questions, please call our Provider Contact Center at 1-866-431-0802 (toll free).

PW_2011_528

Effective December 12, 2011, a new payment search feature is available for all providers using the provider web portal. This search feature allows you to search for a payment by any of the following:

• Check number
• Member number
• Payment date range
  

This feature also allows providers to find $0 remittances.

1. To use this new feature, click on Payment Search under the "Provider Inquiries" menu in the provider portal.
   
   
   
2. Once the search screen opens, enter a check number, member ID, or the payment from and to dates. Press enter or click Search to complete your search for payment information.
   
   
   
3. When a payment is found that matches your criteria, you can click on the check number to view more information about that particular check, including all claims paid by that check. You can also click on View EOP to view the Explanation of Payment (EOP).

PW_2011_535

As part of our contractual requirements with the State, PrimeWest Health is required to ensure all sources of service coverage are considered prior to our payment on claims.

To aid us in this process, we have recently begun working with Discovery Health Partners (DHP) in COB efforts. We are informing our providers of this relationship so that in the event you receive a phone call from a DHP specialist, you are aware that DHP has partnered with PrimeWest Health in COB processes.

PW_2011_544

Reimbursement for C&TC screening services is dependent upon referral codes on the claim. The claim should include one of the four appropriate referral codes depending on the referral reasons. Only one of the referral codes should be used on the claim, and it should be included on all line items of the claim.

PrimeWest Health also requires the S0302 code as a line item on the claim form. By submitting the S0302 code, the provider is indicating to PrimeWest Health that a full C&TC screening was completed. This line item should also include the required referral code.

Claims submitted without a referral code on all line items will be denied. Please refer to Chapter 9, Children's Services, of the PrimeWest Health Provider Manual for details on billing C&TC services.

PW_2011_532

The Minnesota Department of Human Services (DHS) recently published several changes to their provider manual regarding laboratory services. PrimeWest Health will be following these changes, which include the following:

Specimen Collection and Handling

Effective for dates of service on and after January 1, 2012, PrimeWest Health will no longer reimburse for collection of blood by venipuncture (CPT 36416), capillary (CPT 36415), or access port (CPT 36591 and 36592) in conjunction with another service. These services are incidental or included in a primary service.

PrimeWest Health will cover collection and handling (if applicable) for each type of specimen listed below, per member, per day:

• Routine venipuncture for collection of specimens; use CPT 36415 (for dates of service on and after January 1, 2012, the above policy applies)
• Collection of Pap smears; use CPT Q0091
• Catheterization for collection of a specimen, single homebound, nursing facilities; use CPT P9612
• Catheterization for collection of a specimen, multiple recipients; use CPT P9615
• Newborn screening for metabolic disorder  

Effective for dates of service on or after January 1, 2012, in accordance with MN Stat. sec. 144.123, PrimeWest Health will only cover handling and/or conveyance of specimen (CPT 99000) if both of the following apply:

• A specimen (biological) is required to be submitted to the Minnesota Department of Health (MDH) for disease prevention or control purposes (MN Rules part 4605.7040)
• The provider utilizes a third party courier and incurs a fee to deliver the biological to MDH 

If both of the proceeding conditions are met, you may claim the courier expense using the 837P. You must identify the rendering provider as MDH (UMPI #306253800). In all other instances, this service is incidental to the primary service and is not covered

Modifiers for Genetic Testing

Genetic testing modifiers are used to define the type of genetic test being completed. Genetic code modifiers are always required when reporting genetic lab CPT codes (molecular diagnostic procedures 83890 – 83914 and cytogenetic procedures 88230 – 88299).

Modifier 76: Used to indicate the same physician repeated the same service or procedure within the same day or whenever the circumstance warrants it. Use this modifier to indicate that a repeated service or procedure was necessary and that it does not represent a duplicate bill. An explanation of the medical necessity of the repeat procedure is necessary.

Modifier 77: Used to indicate a different physician repeated the same service or procedure, usually within the same day. An explanation of the medical necessity of the repeat procedure is necessary.

Modifier 90 (reference [outside] laboratory): Used to identify laboratory procedures performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified lab other than the treating or reporting physician.

Modifier 91: Used to indicate a repeat clinical diagnostic laboratory test (CPT code) on the same date of services, at different intervals to obtain subsequent, additional test results. Bill laboratory services in units that are run on the same day and not repeated. The 91 modifier may only be used for laboratory tests paid under the clinical laboratory fee schedule (for example: repeating an arterial blood sample or potassium test at different intervals on the same day).

Repeat modifier 76, 77, and 91 may not be used when:

• There are standard CPT/HCPCS codes available that describe a series of results (e.g., glucose tolerance tests, evocation/suppression tests, etc.)
• Tests are run to confirm initial results due to testing problems with the specimen or equipment
• For any other reason when a normal, one-time, reportable result is required

Modifier 92 (alternative laboratory platform testing): Used when laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use disposable analytical chamber. Only to be used with HIV testing CPT codes 86701 – 86703.

Modifier 99 (multiple modifiers): Used when multiple modifiers are needed to fully describe a service. If more than one modifier is necessary on a code, also apply modifier 99.

When billing pathology codes, modifiers 76, 77, and 91 are allowed. Modifiers 22 and 52 cannot be used when billing pathology codes.

Oncotype Dx Testing for Breast Cancer

Oncotype Dx testing is a 21 gene assay test, which aims to help breast cancer patients and their physicians determine whether adjuvant chemotherapy would be beneficial. For dates of service on or after January 1, 2012, testing is considered medically indicated for members with the all of the following breast cancer characteristics:

• Stage I or II breast cancer
• Breast tumor is estrogen-receptor positive
• Breast tumor is HER2-receptor negative
• Tumor size is 0.6 – 1 cm with moderate/poor differentiation or unfavorable features, or tumor size is greater than 1 cm
• Negative lymph nodes (nodes with micrometastases greater than 2 mm in size)
• Test result will be used to guide decision making about adjuvant chemotherapy

PW_2011_515