Personal Care Assistant (PCA) provider agencies actively enrolled and providing PCA services between July 1, 2010, and June 30, 2011, must complete a service delivery data request by June 20, 2013.

The Personal Care Assistance–Quality Assurance (PCA-QA) unit requires agencies to complete self-report reviews annually. These reviews are part of a continued effort to maintain PCA program integrity.

For additional information on the 2013 service delivery review, please visit the Minnesota Department of Human Services (DHS) website.

Minnesota Health Care Programs (MHCP) requires any providers who wish to continue to provide waiver services and receive reimbursement for these services on or after January 1, 2014, to complete a record review.

During the review process, providers complete and submit forms to report the services they are currently providing or want to continue to provide and submit the approved service credentials as proof they are qualified to provide the service.

For additional details on the review process, please see the Provider Record Review information on the DHS website.

According to the April 2013 American Academy of Pediatrics Oral Health E-Newsletter, the American Academy of Pediatrics (AAP) will be hosting a free webinar on June 3, 2013, from 12 – 1:30 p.m. regarding pregnant women and oral health care called “Working Together to Promote Oral Health Care for Pregnant Women.” As noted in the newsletter, this webinar will:

• Highlight Oral Health Care During Pregnancy: A National Consensus Statement
• Share what health professionals can do in their practices and ways to work with other health professionals to promote the importance and safety of oral health care for pregnant women
• Discuss key concepts around prevention, disease management, treatment, anticipatory guidance, and connecting with community resources
• Focus on common concerns of health professionals (liability) and pregnant women

Register today for this free webinar!

The following is important information regarding this webinar from the AAP PediaLink^® Online Center for Lifelong Learning:

• The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
• The AAP designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
• The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s)™ from organizations accredited by the ACCME.
• This activity is acceptable for a maximum of 1.50 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the AAP.

For more information, please see the AAP newsletter or contact oralhealth@aap.org.

The next installment of our popular Lunch & Learn series is scheduled for Thursday, June 20, 2013, from 11 a.m. – 1 p.m. at Grand Arbor in Alexandria. We encourage you to join us for training on falls prevention—an issue of great importance in senior service delivery. Consider the following information from the Centers for Disease Control and Prevention (CDC):

Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.

• One out of three adults age 65 and over falls each year, but less than half talk to their healthcare providers about it.
• Among older adults (those 65 or older), falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.
• In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.
• In 2010, the direct medical costs of falls, adjusted for inflation, was $30.0 billion.

As you can see, the statistics are alarming, and we encourage you to attend this training to learn how you can be part of the solution.

Pre-registration is required by June 10. To register, please email Chrissy Harris at chrissy.harris@primewest.org and include your name, facility, address, phone number, email address, and any specific topics you wish to see addressed. Please put “Lunch & Learn” in the subject line.

Source: CDC

PrimeWest Health is pleased to share information regarding our current Performance Improvement Projects (PIPs). Minnesota health plans are required to initiate a new PIP each year for contracted populations. These projects are often a collaborative effort between multiple plans and the numerous stakeholders that may be involved in planning, implementing, and measuring success. The PIP News newsletter provides summaries of current projects being implemented across the state and important ways providers and others can support these efforts.

Please contact Jordan Klimek, PIP/HEDIS Coordinator, at 1-320-335-5364, 1-888-588-4420 ext. 5364 (toll free), or jordan.klimek@primewest.org with any questions or comments.

The Centers for Medicare & Medicaid (CMS) revised Medicare Learning Network (MLN) Matters # MM6993 to inform physicians, clinical diagnostic laboratories, and other providers who bill Medicare contractors (carriers or Medicare Administrative Contractors [A/B MACs]) for providing diagnostic imaging services to Medicare beneficiaries of the technical component (TC) reduction.

This article is based on Change Request (CR) 6993, which announced that Medicare would be changing the multiple procedure payment reduction (MPPR) on the TC of certain diagnostic imaging procedures. Effective January 1, 2011, CMS consolidated the existing 11 advanced imaging families into a single family. This change applies: 1) When two or more services on the list are furnished to the same patient in a single session; and 2) Only to the TC portion of global services, not to the professional component (PC). Medicare will continue to make the full TC payment for the procedure with the highest priced TC and will pay 50 percent each for the TC of each additional procedure on the same patient in the same session. Effective June 26, 2013, PrimeWest Health will follow Medicare on the reduction on the TC of certain diagnostic imaging procedures.

If you have additional questions, please review MLN Matters # MM6993 or call the Provider Contact Center at 1-866-431-0802 (toll free).

The Centers for Medicare & Medicaid (CMS) recently posted Medicare Learning Network (MLN) Matters # MM8256 for providers and suppliers who submit claims to Medicare contractors (Fiscal Intermediaries [FIs] and/or A/B Medicare Administrative Contractors [A/B MACs]) for End Stage Renal Disease (ESRD) services provided to Medicare beneficiaries.

This article is based on Change Request (CR) 8256, which instructs ESRD facilities to append the new modifier, JE (Administered via Dialysate), to all ESRD claims with dates of service (DOS) on or after July 1, 2013, where drugs and biologicals are furnished to ESRD beneficiaries via the dialysate solution. PrimeWest Health will be following this requirement in the processing of ESRD claims.

Please make sure that your billing staff is aware of this change. If you have additional questions, please see MLN Matters # MM8256 or call the Provider Contact Center at 1-866-431-0802 (toll free).

On February 25, 2013, PrimeWest Health posted an update informing providers that PrimeWest Health follows the 5010 standards for electric submission of claims and requires a street address in the Billing Provider and Service Facility Location in the 837 claim formats.

As a reminder, effective April 10, 2013, all claims submitted with a Post Office (PO) Box or Lock Box in the Address1 or Address2 fields in the Billing Provider or Service Facility Location will be rejected back to the provider. This rule applies to all 837 claim formats (professional, institutional, and dental).

Providers can only use a PO Box or Lock Box in the Pay-To Address location of the 837 claim formats. The Pay-To-Provider address is only used if the address is different than the Billing Provider address. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claims submission.

If you need clarification for entry of claim address information, see the 837 issue brief created by the Workgroup for Electronic Data Interchange (WEDI), “Billing Provider and Pay-To Address Reporting.”

When you click on the link above to access this document, you will be asked to enter your user ID and password for the WEDI website. If you do not already have a user ID/password, you will be asked to set up a free account.

Effective January 1, 2013, the meningococcal (Current Procedural Terminology [CPT] code 90734) and polio (CPT code 90713) vaccines for adults (age 19 and over) are no longer available through the Minnesota Health Care Programs (MHCP) Adult Program at the Minnesota Department of Health (MDH). Providers will need to purchase doses of the meningococcal and polio vaccines for adults and will need to bill PrimeWest Health for the vaccine and vaccine administration.

Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will deny Part B, durable medical equipment (DME), and Part A home health agency (HHA) claims for services or supplies that require an ordering/referring provider to be identified when the provider is not enrolled with CMS.

If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O).

PrimeWest Health will follow the CMS ordering/referring provider enrollment requirement. If the ordering/referring provider listed on claims for Medicare Part B services, DME, or Part A HHA services is not enrolled with CMS, your claim will be denied. If this information is missing or incorrect, the following types of claims will be denied:

• Claims from laboratories for ordered tests
• Claims from imaging centers for ordered imaging procedures
• Claims from suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for ordered DMEPOS
• Claims from Part A HHAs

Please refer to Medicare Learning Network (MLN) Matters Special Edition # SE1305 for complete details on this requirement.

PrimeWest Health requires providers to bill using the most appropriate code to describe the item or service supplied to a member. In the cases where there isn’t a specific code for a service, a miscellaneous code may be used. All claims submitted with a miscellaneous code must include a description. If the description is not included, the claim will be denied.

When billing for multiple products that are different but require the use of the same miscellaneous Healthcare Common Procedure Coding System (HCPCS) code, use the correct miscellaneous code and modifier for the first line item, and add the 76 modifier to each additional line using the same miscellaneous HCPCS code.

If billing multiple units of the same product, bill using the correct miscellaneous code and modifier and indicate the number of units dispensed.

If you have questions, please review Chapter 23, Equipment and Supplies, of the Provider Manual or call the Provider Contact Center at 1-866-431-0802 (toll free).

Join us for the next installment of our popular Lunch & Learn series!

Please join us on Thursday, June 20, 2013, from 11 a.m. – 1 p.m. at Grand Arbor. Guest speaker Gail Gilman-Waldner, MEd, Professor Emeritus at the University of Minnesota and Program Developer for the Minnesota River Area Agency on Aging, will present information about two evidenced-based programs offered by the Area Agencies on Aging: “Matter of Balance” and “Chronic Disease Self-Management – Live Well with Chronic Conditions.” Both of these programs include tools and techniques to help participants feel better, have more control, and take part in activities they enjoy. This will keep our aging population mobile, independent, and in their own homes and communities for as long as possible.

Date: Thursday, June 20, 2013
Time: 11 a.m. – 1 p.m.
Location: Grand Arbor
             4403 Pioneer Rd SE
             Alexandria, MN 56308

Pre-registration is required by June 10. To register, please email Chrissy Harris at chrissy.harris@primewest.org and include your name, facility, address, phone number, email address, and any specific topics you wish to see addressed. Please put “Lunch & Learn” in the subject line.

Effective June 8, 2013, PrimeWest Health will be following Medicare guidelines for reimbursement for multiple endoscopic procedures performed for the same patient on the same day during the same session.

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

PrimeWest Health is lifting the threshold limits for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) for all PrimeWest Health Medical Assistance (Medicaid) members (Prepaid Medical Assistance Program [PMAP], MinnesotaCare, Minnesota Senior Care Plus [MSC+], and Special Needs BasicCare [SNBC]), effective January 1, 2013.

All PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) members will continue to have the Medicare therapy cap (dollar limit) when they have Medicare coverage (including members residing in a nursing home). Once the dollar limit is reached on the therapy cap, claims will be processed following Medicaid guidelines.

Non-contracted providers must follow our standard process and obtain authorization for all services provided to PrimeWest Health members unless Medicare is the primary payer.

If you have any questions, please see Chapter 17, Rehabilitation Services, of the Provider Manual, or call the Provider Contact Center at 1-866-431-0802 (toll free).

PrimeWest Health pays chemical dependency (CD) claims per the authorizations generated from the Client Placement Authorization (CPA) forms submitted to PrimeWest Health and the information housed in the Minnesota Information Transfer System (MN-ITS), the Health Insurance Portability and Accountability Act (HIPAA)-compliant web-based electronic billing and administrative transaction system provided by the Minnesota Department of Human Services (DHS).

The CPA is submitted to PrimeWest Health by the client’s county of residence, Rule 25 assessor, county designee, or tribe. The CPA form indicates the level of treatment the client will be receiving by the correlating modifiers, codes, and rates listed.

Within MN-ITS, there is a direct link to an interactive web page displaying the Consolidated Chemical Dependency Treatment Fund (CCDTF) rate sheet that contains the modifiers, codes, service types, and rate information for all CD residential, outpatient, and medication-assisted therapy providers contracted with DHS. The CCDTF rate sheet is updated regularly with the most current information regarding treatment tracks, modifiers, codes, and rate information offered by each CD provider.

To ensure timely payment of claims, it is crucial you review the information regarding your program in MN-ITS and confirm it is the same information that was provided to PrimeWest Health on the CPA form. If you find a discrepancy in the information listed for your program:

• in MN-ITS: contact DHS immediately to have it corrected
• on the CPA form: contact the county, Rule 25 assessor, county designee, or tribe immediately to have the CPA corrected and resubmitted to PrimeWest Health

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

You are invited to the Fall 2013 Providers & Partners Conference on Tuesday, September 24, 2013, at the Holiday Inn, 5637 Hwy 29 S, Alexandria, MN.

This will be an all-day event with guest speakers, trainings, and complementary lunch. Please watch the PrimeWest Health website for additional information.

Continuing education units (CEUs) are pending.

Effective May 30, 2013, claims received from all new providers or providers who have made a change to their National Provider Identifier/Unique Minnesota Provider Identifier/Taxpayer Identification Number (NPI/UMPI/TIN) and have not notified PrimeWest Health will be rejected.

Providers will be required to complete or update the Provider NPI/UMPI Notification/Request, Request for Taxpayer Identification Number and Certification (W-9), and Electronic Remittance Advice (835) Registration Form. Current providers must also update the Facility Change/Update Form, while new providers must complete the Facility Information for Non-Contracted Providers form. All providers must return the information by fax or mail. PrimeWest Health will enter the provider’s information into our claims processing system within 15 days of receiving the information. Please wait 15 days before resubmitting your claims.

Should you have additional questions, please call the Provider Contact Center at 1-866-431-0802 (toll free) or visit the PrimeWest Health website to review all provider forms related to change and updates.

Non-participating providers can visit our web page on forms and requirements for submitting your first claim to PrimeWest Health.

The Minnesota Department of Human Services (DHS) and Minnesota Health Care Programs (MHCP) has added the following new electronic documents to its website that pertain to MHCP’s waiver provider enrollment process, which is currently underway in preparation for implementation of the revised MN Stat. Chap. 245D and statewide waiver provider standards effective January 1, 2014.

• Waiver and Alternative Care (AC) Programs Provider Enrollment Application (DHS-4015)
• MHCP Provider Agreement (DHS-4138)
• Disclosure of Ownership Interest (DHS-5259)
• Assurance Statement (as appropriate)
• Lead Agency Enrollment Request Form (DHS-6383)
• Waiver and Alternative Care (AC) Programs Service Request Form
  (DHS-6638)
• Proof of licenses or certifications (as appropriate)

DHS developed the assurance statements for providers to attest that they are providing a specific service. Each assurance statement allows the provider to assure DHS of actions they will take when providing the service, including assurance of background study requests for all direct care staff.

The records review must be completed by May 31, 2013. Upon completion of the review, DHS will update the enrollment records and send a new enrollment letter to summarize the approved services on the provider’s record.

For additional information, providers may contact the MHCP Provider Call Center at
1-800-366-5411 (toll free).

PrimeWest Health is excited to announce the release of our eligibility and health care claim status web service.

Due to changes associated with the 5010 mandate and the upcoming Committee on Operating Rules for Information Exchange (CORE) Operating Rules for Eligibility and Healthcare Claim Status, PrimeWest Health has been working on changing the process for handling requests for eligibility and claim status. Providers will now be able to establish a direct connection to the PrimeWest Health web service, allowing them to check member eligibility and claim status for PrimeWest Health members.

Providers that are currently using their clearinghouse or system vendor to access PrimeWest Health eligibility records should contact their current clearinghouse or system vendor to request a direct connection to the PrimeWest Health web service.

If you currently use Emdeon to verify PrimeWest Health eligibility, you will need to modify your process. As of April 29, 2013, Emdeon will no longer be hosting PrimeWest Health eligibility data. If you attempt to access eligibility data via Emdeon, you will receive a system error.

If you currently use Emdeon or if your clearinghouse or system vendor will not be creating a connection to the PrimeWest Health web service for you, additional options for checking eligibility and/or claim status for PrimeWest Health members are available in Chapter 4, Billing Policy, of the PrimeWest Health Provider Manual.

If you have any questions regarding direct connection to PrimeWest Health’s web service, please email edisupport@primewest.org.

Effective May 25, 2013, PrimeWest Health will follow the multiple procedure payment reduction (MPPR) for selected therapy services. This reduction will be revised to 50 percent for all settings, according to the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN) Matters # MM8206.

Currently, a 20 percent MPPR is applied to the practice expense (PE) for therapy services furnished in office and other non-institutional settings and a 25 percent reduction is applied for therapy services furnished in institutional settings.

The MPPR applies to the PE payment when more than one unit or procedure is provided to the same patient on the same day. Full payment is made for the unit or procedure with the highest PE and 50 percent payment will be made for the PE for subsequent units and procedures.

Please make sure your billing staff is aware of this update. If you have additional questions, please see MLN Matters # MM8206 or call the Provider Contact Center at
1-866-431-0802 (toll free).

PrimeWest Health uses the ANSI ASC X12 277CA claims acknowledgement to notify providers who have submitted claims in the 5010 837 claim format that their claim has been rejected. Claims that do not reach our claims processing system because they received an error based on PrimeWest Health’s front-end edits are communicated on the acknowledgment back to the clearinghouse, which is then forwarded to the provider. This acknowledgement is important because it includes the reason for the error so the provider can correct and resubmit the claim.

If you currently do not receive rejected claims information from your designated clearinghouse, we encourage you to contact your clearinghouse and follow their procedures for registering to receive the rejected claims information. This information can be used to reconcile submitted claims against those received by PrimeWest Health.

As a courtesy, PrimeWest Health also provides error rejections to providers on our provider web portal. You can register through our website by completing our Web Portal Registration Form.

PrimeWest Health encourages providers to verify claim status on a regular basis using our provider web portal to avoid timely filing denials. PrimeWest Health guidelines require claims to be submitted correctly and received no later than 180 days from the date of service or 180 days from payment resolution with Medicare or the third party liability payer. If you are not able to locate your claim in our portal, please check with your clearinghouse to verify the claim was received. If you have additional questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

On February 5, 2013, PrimeWest Health posted a Provider Update on services that are now covered for non-pregnant adults. PrimeWest Health has received several calls from providers asking for clarification. Effective January 1, 2013, relines, repairs, and rebases do not require authorization after 180 days of the initial denture placement. The provider is responsible for relines, repairs, and rebases during the first 180 days of placement.

The 2009 Legislation required the Minnesota Department of Human Services (DHS) to develop a standardized training for those who want to enroll as an individual personal care assistant (PCA) provider. The individual must successfully complete the training prior to enrollment with Minnesota Health Care Programs (MHCP) as an individual PCA provider.

New Hire/Rehire Enrollment and Affiliation

Effective for all applications submitted on or after May 1, 2013, PCA agencies must include the following information about the individual PCA provider if he/she is a new hire or rehire to the PCA agency:

• Date training completed
• PCA training certificate number

MHCP will only affiliate a new or rehired PCA beginning on, or after, the date the person:

• successfully completes the PCA training; or
• has cleared or received a set aside for the background study with the PCA agency, whichever is later.

MHCP is updating the following two forms to include requirements about the PCA training:

• Individual PCA Enrollment Application (DHS-4469)
• Individual PCA Information Change Form (DHS-5716)

The revised forms will be available beginning May 1, 2013. PrimeWest Health requests that all PCA providers complete an assurance statement on an annual basis confirming they have completed these MHCP required trainings and verifications.

For additional information on PCA provider training, please visit the DHS website.

On March 12, 2013, the Food and Drug Administration (FDA) issued a drug safety communication regarding findings that azithromycin can cause irregular heart rhythms. A portion of the communication is below.

The U.S. Food and Drug Administration (FDA) is warning the public that azithromycin (Zithromax or Zmax) can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm. Patients at particular risk for developing this condition include those with known risk factors such as existing QT interval prolongation, low blood levels of potassium or magnesium, a slower than normal heart rate, or use of certain drugs used to treat abnormal heart rhythms, or arrhythmias. This communication is a result of our review of a study by medical researchers as well as another study by a manufacturer of the drug that assessed the potential for azithromycin to cause abnormal changes in the electrical activity of the heart.

The azithromycin drug labels have been updated to strengthen the Warnings and Precautions section with information related to the risk of QT interval prolongation and torsades de pointes, a specific, rare heart rhythm abnormality. Information has also been added regarding the results of a clinical QT study which showed that azithromycin can prolong the QTc interval.

Health care professionals should consider the risk of fatal heart rhythms with azithromycin when considering treatment options for patients who are already at risk for cardiovascular events (see Additional Information for Health Care Professionals below).  FDA notes that the potential risk of QT prolongation with azithromycin should be placed in appropriate context when choosing an antibacterial drug: Alternative drugs in the macrolide class, or non-macrolides such as the fluoroquinolones, also have the potential for QT prolongation or other significant side effects that should be considered when choosing an antibacterial drug.

For the full safety announcement, visit the FDA website.

On March 20, 2013, the Food & Drug Administration (FDA) announced a voluntary recall of all sterile products distributed by Clinical Specialties compounding pharmacy. A portion of the FDA press release is below.

Clinical Specialties is voluntarily recalling All Lots of All Sterile products repackaged and distributed by the pharmacy due to lack of sterility assurance. The recall of all sterile products is conducted in follow-up to concerns regarding practices at the site which cannot assure the sterility of the products. The expanded recall follows the firm’s initial recall of Avastin due to reports of five patients who have been diagnosed with serious eye infections associated with the use of the product. Although there has been no evidence of contamination with sterile products other than the specified Avastin lots, Clinical Specialties has decided in the interest of their patients to proceed with this recall process.

The Center for Disease Control and Prevention (CDC) notified the FDA of these endophthalmitis infections, which occur inside the eyeball. Endophthalmitis after intravitreal injection is a serious complication that can lead to permanent loss of vision. Clinical Specialties Compounding repackaged the Avastin into individual single-use syringes from the manufactured vials labeled as sterile.

A compromised sterile product puts patients at risk for serious and possible life threatening infection.

Clinical Specialties Compounding sterile products covered under this recall were distributed nationwide between October 19, 2012 and March 19, 2013. Until further notice, health care providers should stop using all sterile products distributed by Clinical Specialties Compounding and return them to the company.

Consumers or Health Care providers with questions regarding this recall may contact Clinical Specialties by phone at 866.880.1915 or e-mail address at clinicalrx@bellsouth.net; Monday through Friday between the hours of 10 am to 5 pm EST. Patients who have received any product distributed by Clinical Specialties Compounding and have concerns should contact their healthcare provider.

For the full press release, visit the FDA website.

Minnesota Health Care Programs (MHCP) is offering multiple two-hour training webinars to provide instruction about the overall process for completing the provider record review for anyone providing waiver or Alternative Care (AC) program services or others who are interested. All waiver/AC providers are required to complete a waiver provider record review before July 1, 2013.

For dates, times, and registration information, please visit the Minnesota Department of Human Services (DHS) website.

The Centers for Medicare & Medicaid (CMS) recently posted Medicare Learning Network (MLN) Matters # MM8153 about the recovery of annual wellness visit (AWV) overpayments.

This article is based on Change Request (CR) 8153, which provides instructions to Medicare contractors for recovering AWV overpayments.

Medicare has updated the requirements and will now only allow payment for AWV on one claim. Procedure codes G0438 and G0439 are excluded from payment under the Outpatient Prospective Payment System; instead, payment is made under the Medicare physician fee schedule (MPFS). Medicare will pay either the practitioner or the facility for furnishing the AWV in a facility setting, and only a single payment under the MPFS will be allowed.

Please make sure that your billing staff are aware of these changes and view MLN Matters # 8153 for details on AWV overpayments.

Proper place of service (POS) coding
The Centers for Medicare & Medicaid (CMS) revised Medicare Learning Network (MLN) Matters # MM7631 to alert providers to the latest POS coding instructions and clarify national policy for POS code assignment. MLN Matters # MM7631 was based on Change Request (CR) 7631, which provided instructions regarding the assignment of POS codes for all services paid under the Medicare physician fee schedule (MPFS), for certain services provided by independent laboratories, and for the interpretation (Professional Component [PC]) and the Technical Component (TC) of diagnostic tests.

New POS code available
MLN Matters # MM8125, based on CR 8125, updates the current Medicare POS code set to add a new code: 18 – Place of Employment/Worksite, described as “a location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic, or rehabilitative services to the individual.”

CMS is establishing this POS code for the following reasons:

1. Industry entities (other than Medicare) have identified a need to establish the delivery of occupational-related medical and rehabilitation services in the workplace in order to:
   1. reduce employee time lost from work; and
   2. enable therapists to evaluate the work environment and provide rehabilitation services that are focused on returning the individual to his/her pre-injury state in a way that maximizes function in the workplace environment and reduces employee time lost.
2. As a Health Insurance Portability and Accountability Act of 1996 (HIPAA)-covered entity, Medicare must comply with its standards and implementation guides that are adopted by regulation. Specifically, the currently adopted professional implementation guide for the Accredited Standards Committee (ASC) X12 837 (professional health care claim) standards requires that each electronic claim transaction include a POS code from the POS code set that CMS maintains.

Please refer to MLN Matters # MM7631 and MLN Matters # MM8125 for more information.

PrimeWest Health’s “HCBS for 2013: What’s On The Horizon?” Lunch & Learn was a great success! If you were unable to attend or would like to review any of the information, we have posted the PowerPoint presentation on our website and have linked to MN Stat. Chap. 245D. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

Effective May 1, 2013, PrimeWest Health will follow Minnesota Department of Human Services (DHS) requirements on continuous positive airway pressure (CPAP) devices, limiting members to one CPAP device every five years.

For additional information on CPAP services, please refer to Chapter 23, Equipment and Supplies, of the PrimeWest Health Provider Manual or call the Provider Contact Center at 1-866-431-0802 (toll free).

As a part of the Final Calendar Year (CY) 2013 Call Letter, the Centers for Medicare & Medicaid Services (CMS) introduced requirements for Medicare Part D plans to prevent overutilization of opioid medications through a case management process. PrimeWest Health and Prime Therapeutics, our pharmacy benefits manager (PBM), have developed criteria to address these requirements for members of PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP).

Each quarter, members who receive high daily dosages of drugs containing opioids and/or acetaminophen will be identified. The opioid case management team will send the prescriber(s) of these drugs a letter providing background on the identified member’s potentially inappropriate medication utilization and asking the provider to verify whether the drug is necessary as written to treat the member. Providers are asked to complete a form and fax it back to the case management program. If the form is not returned, attempts will be made to call the provider’s office. If a response is not received and contact is not made, the drug will be deemed not medically necessary and will no longer be covered until additional information is received.

Based on the response from the provider(s), a determination will be made on the medical necessity of the opioid and/or acetaminophen drug(s) being prescribed to the member. The drugs may be deemed one of the following:

• Necessary
• Necessary, with restriction to a certain drug or quantity limitation
• Not medically necessary. Future prescriptions for drugs deemed not medically necessary will not be covered.

Letters will be sent to the member and the provider notifying them of the determination. Any coverage limitations will not take place until 30 days after the letter is sent. When inappropriate utilization has been identified and restrictions or limitations put into place, prescriptions exceeding the determined restriction or limitation will be rejected at the pharmacy with the message, “Drug and/or quantity not covered: case management.” Members and providers can Appeal the decision by submitting a coverage determination request to override the decision made by case management.

If you have questions, please contact Jayme Steig, Pharmacy Manager, at 1-320-335-5216, 1-888-588-4420 ext. 5216 (toll free), or jayme.steig@primewest.org.

The technical issue with the provider web portal that was causing remittances from March 7, 2013, not to display has been resolved. We apologize for any inconvenience this may have caused.

The Alcohol & Drug Abuse Division (ADAD) of the Minnesota Department of Human Services (DHS) has recently determined that the time definition assigned to procedure code H0005 is inappropriate. To correct this error, the code for outpatient group treatment will be changed. For dates of service after March 1, 2013, please use procedure code H2035 with the HQ modifier for outpatient group treatment services. Procedure code H2035, currently used for outpatient individual treatment, will remain the same.

Procedure code H0020 will continue to be used for methadone services, but an additional code, H0047, will be used to allow for clearer distinction between MAT (methadone) and MAT (all other). For service dates on or after March 1, 2013, procedure code H0047 with the U9 modifier is to be used for MAT (all other), and H0047 with the UB modifier is to be used for MAT Plus (all other). You will still need to identify which medication is being used by placing the appropriate value (M, A, N, B, or O) in the Drug Code field on the Service Agreement.

To implement these new codes, all Service Agreement lines using the old codes ended on February 28, 2013, with new lines using new codes taking effect March 1, 2013. A coding crosswalk is provided below for your reference.

Additional modifiers may be used to identify the service track, but these will not be included on the claim when billing.

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

PrimeWest Health has found that claims submitted with Current Dental Terminology (CDT) codes D0220 and D0230 are being erroneously rejected. The rejections incorrectly indicate that the codes require a mouth location or tooth number. The edit for these codes has now been removed.

If your facility has received a rejection notice from your clearinghouse for these codes, please resubmit your claim to PrimeWest Health for reprocessing.

We apologize for any inconvenience this may have caused. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

The provider web portal is currently experiencing technical issues, causing provider remittance advices from March 7, 2013, not to display. We are working to resolve this issue.

In the interim, please call our Provider Contact Center at 1-866-431-0802 (toll free) for assistance.

We apologize for any inconvenience this may cause and will update you once access to the remittance advices is restored completely.

Thank you for your patience.

The Minnesota Department of Health (MDH) offers a wide variety of grant and loan programs to counties, non-profits, schools, private individuals, and others. Please visit the Minnesota Department of Health website for more information on available grants and loans.

Eligible applicants:

The provider web portal is currently experiencing technical issues resulting in intermittent access at this time.

Please call our Provider Contact Center at 1-866-431-0802 (toll free) for assistance in the interim.

We apologize for any inconvenience this may cause and will update you once access is restored completely.

Due to the winter storm approaching Minnesota, the Elderly Waiver (EW) Home and Community Based Services (HCBS) Lunch & Learn scheduled for Tuesday, March 5, 2013, has been rescheduled for Friday, March 8, 2013.

If you have any questions, please email Chrissy Harris at chrissy.harris@primewest.org or call the Provider Contact Center at 1-866-431-0802 (toll free).