Additional information has been added to this Provider Update since the original November 10, 2011 posting.

On October 26, 2011, the Minnesota Second Judicial District Court issued a temporary restraining order regarding Personal Care Assistant (PCA) relative caregiver reimbursement rates. Until PrimeWest Health is ordered to do otherwise, we will pay PCA relative caregiver claims at the same rate as non-relative caregivers. This rate change is effective immediately and will apply to claims with a date of service on or after October 1, 2011.

PrimeWest Health will be adjusting all PCA claims that were paid the reduced rate due to relative caregiver status for dates of service on or after October 1, 2011. Please do not submit claim adjustment requests to PrimeWest Health for this purpose.

In accordance with this order, providers must continue to identify and document the relationship of each individual PCA provider with each member for whom they provide services. Please report relationship information on claims you submit for PCA services per the instructions in Minnesota Department of Human Services (DHS) provider update PCA-11-02R. Specifically, identify the relationship on the claim through the use of modifiers. Claims missing this identifier will be denied. In addition:

• Complete the Minnesota Department of Human Services (DHS) Individual PCA Relationship Acknowledgment for each individual PCA provider and keep this form in your agency's files and the member's health service record.

• Identify the relationship on your agency's PCA Time and Activity Documentation each pay period and keep this form in your agency's files.

DHS has issued provider update PCA-11-03 to provide additional details about this recent payment change.

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You can now find a link to PrimeWest Health's Provider Contact Center information on our website. From the Providers & Partners tab, click on Provider Contact Center in the green navigation bar on the left side of your screen. This link will take you to the Provider Contact Center's hours and contact information, and we will keep the page updated with the dates PrimeWest Health and the Provider Contact Center will be closed.

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It is the provider's responsibility to submit Critical Access Hospital (CAH) rates to PrimeWest Health and update PrimeWest Health with any changes to the rates prior to the submission of claims for that rate period. Once PrimeWest Health receives the updated rates, please allow up to 30 days for programming of the rates to be completed. We do not reprocess claims received prior to the date the change is made in our system.

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Effective January 1, 2012, Health Care Home (HCH) services will require a Service Authorization. HCH providers must complete and submit the Medical Service Authorization Request Form and the Care Coordination Tier Assignment Tool.

The PrimeWest Health member's HCH care plan and related documentation will be requested and reviewed to ensure the member's health and social needs are met and that the HCH is meeting statutory requirements. HCH providers must follow and meet MN Rules part 4764.0040, Health Care Home Standards, and additional PrimeWest Health requirements in order to qualify for HCH payment. PrimeWest Health expects HCH providers to collaborate with other identified care coordinators and county case managers. Periodic audits of HCH providers may be conducted to ensure the quality of HCH services provided to our members.

The PrimeWest Health Provider Manual is currently being updated to reflect these changes.

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Recently Healthcare Common Procedure Coding System (HCPC) codes G0281 and G0282 for electrical stimulation were determined to be considered investigative. Therefore, effective October 3, 2011, they are no longer considered a covered service. Claims received at PrimeWest Health with these codes will be denied as having invalid codes.

G0281 – Electrical stimulation, to one or more area, for chronic Stage III and Stage IV pressure ulcer, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care.

G0282 – Electrical stimulation to one or more areas for wound care other than described in G0281.

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As a reminder, on January 1, 2012, PrimeWest Health will be changing where your dental claims are processed. PrimeWest Health mailed out a flyer on November 3 to provide you with some key points to be aware of when submitting claims after January 1, 2012.

The mailing also included information regarding the PrimeWest Health-hosted Lunch & Learn scheduled for Thursday, December 8, in Alexandria.

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The Minnesota Department of Human Services (DHS) has posted several upcoming training workshop dates for Personal Care Assistant (PCA) providers. These three-day "PCA Steps for Success" workshops are required for all new owners or employees in management and supervisory positions involved in the PCA agency's day-to-day operations. Please see the update on the DHS website for more information.

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The Minnesota Department of Health (MDH) has announced a grant program to help health care providers, hospitals, and pharmacies in rural and underserved areas build health information exchange (HIE) capacity and achieve HIE capability. Grant awards range up to $10,000, and applications will be reviewed and evaluated on a first come, first served basis. Visit the Minnesota e- Health Connect web page for more information on this new funding opportunity, including the Program Guidance and grant application.

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On January 1, 2012, PrimeWest Health will be changing where your dental claims are processed. Claims with a date of service (DOS) through December 31, 2011, will continue to be processed at Midwest Dental Benefits (MDB), and the submission process will remain the same. Claims with a DOS on or after January 1, 2012, will be processed at PrimeWest Health. PrimeWest Health mailed out a flyer on October 14 with more information about this change and how it will affect you.

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PrimeWest Health's October 7, 2011 Lunch & Learn for Customized Living (CL) providers included information on a Minnesota Department of Human Services (DHS) bulletin that had not yet been published. This bulletin, 11-25-05, has now been posted on the DHS website. Please read this bulletin for details on the 2011 legislative changes that affect CL and 24-hour CL.

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Claims submitted for services provided to PrimeWest Health members must reflect the most appropriate place of service (POS) that applies to the claim. Special transportation providers should use POS 99 on their claims.

Claims for special transportation submitted with a POS code other than 99 will be denied as "procedure code/bill type inconsistent with place of service."

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PrimeWest Health's Customized Living (CL) 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. If you have any questions, please call our Provider Contact Center at 1-866-431-0802 (toll free).

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Q2043 is the new code for Provenge^® (previous code was C9273). This drug has received FDA approval for use in very select circumstances. PrimeWest Health will require Service Authorization for this drug effective December 1, 2011. Requests for Service Authorization need to be faxed to PrimeWest Health's Utilization Management department at 1-866-431-0804 (toll free).

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The Centers for Medicare & Medicaid Services (CMS) recently posted an article on balance billing Qualified Medicare Beneficiaries (QMB) titled "Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)." This article provides good clarification on when a provider can and cannot collect payment from a Medicare beneficiary.

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PrimeWest Health follows the Minnesota Department of Human Services (DHS) in their treatment of Personal Care Assistant (PCA) relative caregiver payments (MHCP Provider Update PCA-11-02R).

Effective October 1, 2011, PrimeWest Health requires all PCA agencies to identify, document, and report individual PCA and member relationships for all PCA services provided to PrimeWest Health members, including extended PCA services through the Elderly Waiver program. The PCA agency must identify and document the relationship of each individual PCA provider with each member for whom they provide services:

To do this, the PCA agency must complete the Individual PCA Relationship Acknowledgementand keep it in the agency's files and the member's health service record. This form does not need to be submitted to PrimeWest Health, but it should be kept in the PCA agency's files. Failure to maintain required documentation may result in fines to the PCA provider agency.

PrimeWest Health also requires that the PCA agency report the relationship between the individual PCA provider and the member to PrimeWest Health on the claim form using one of the following two modifiers:

• U1 Parent/adoptive parent, sibling, adult child, grandparent, or grandchild
• UD No relationship/not related

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

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The Fall 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!

Wondering what you're missing? Electronic PrimePointers? It's 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

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As part of the 2011 Minnesota Legislative session, all claims for supplies or services that are based on an order or referral must include the ordering or referring provider's National Provider Identifier (NPI). The ordering or referring provider must also be enrolled in the Minnesota Health Care Programs (MHCP). Claims submitted without this information will deny as "Referring/ordering provider is not registered with MHCP."

Please refer to MN Stat. 256B.02 sec. 24, subd. 5 for details on this legislative change.

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The Minnesota Department of Health (MDH) will be sponsoring three statewide telephone conferences on the implementation of nursing home regulatory guidelines and updates. For more information, please visit the MDH website.

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PrimeWest Health will be hosting a Lunch & Learn for Customized Living (CL) providers on Friday, October 7, 2011, 11 a.m. – 1 p.m. Please see our flyer for more information, including discussion topics and how to RSVP.

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PrimeWest Health believes input from our network providers is critical to ensuring that our approach to managed care and health plan operations reflects the needs and attributes of our contracted providers.

Your thoughts and opinions matter to us and we take them quite seriously. Indeed, past comments and suggestions from providers have helped to shape many PrimeWest Health policies and processes. So, please take a few moments to complete our Provider Satisfaction Survey to help us serve you better.

The survey will be available through September 23, 2011. You do not need to include your name unless you would like us to contact you regarding an issue or comment you have.

Thank you for your time, interest, and support!

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One of the changes to come out of the 2011 legislative session is a change in how Personal Care Assistants (PCAs) are reimbursed and how PCA services are billed. The new legislation requires that when the PCA is a relative of the recipient, reimbursement for services will be at 80 percent of the provider rate.

Beginning October 1, 2011, PrimeWest Health will require Personal Care Provider Agencies (PCPAs) to identify and report the relationship of the individual receiving PCA services to the PCA provider on all PCA claims, including claims for extended PCA services. The Minnesota Department of Human Services (DHS) developed the following modifiers, which are required on services billed as T1019 services (T1019 services are identified as personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment [code may not be used to identify services provided by home health aide or certified nurse assistant)]*:

• U1 – Parent (this includes both biological and adoptive parents) of an adult child
• U2 – Sibling (16 years or over)
• U3 – Adult child
• U4 – Grandparent
• UB – Grandchild
• UD – Not related as U1, U2, U3, U4, or UB

If you bill for PCA services, beginning October 1, 2011, make sure you submit the appropriate modifiers in order to prevent reimbursement denials. These modifiers will not be required for qualified professional services billed as T1019-UA (supervision of PCA services).

For more information regarding PCA services and billing, contact our Provider Services Contact Center at 1-866-431-0802 (toll free).

*American Academy of Professional Coders (AAPC). 2011 HCPCS Level II.

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PrimeWest Health's Chemical Dependency 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. If you have any questions, please call our Provider Contact Center at 1-866-431-0802 (toll free).

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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.

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This information was mailed to dental providers in August 2011.

PrimeWest Health follows the Service Authorization requirements for extractions set forth by the Minnesota Department of Human Services (DHS)* and outlined below. The omission of proper documentation and clinical notes will result in Service Authorization denial.

If you have any questions about the requirements outlined below, please contact Leah Anderson at 1-320-335-5272, 1-888-588-4420 ext. 5272 (toll free), or leah.anderson@primewest.org.

Requesting a Service Authorization for the removal of impacted teeth
As of January 1, 2010, Service Authorization is always required for the removal of an impacted tooth. This affects dental codes D7220, D7230, D7240, and D7241.

To request a Service Authorization for the removal of an impacted tooth, the following dental history, case information, and documentation must be submitted for each tooth to be extracted:

• Third molar extractions must be symptomatic or show evidence of pathology
• Current diagnostic radiographs and chart documentation
• Objective documentation of at least one of the following symptoms:
• Presence of significant infection that includes at least one of the following:
• Severe acute pain/swelling (identify location, severity, and related symptoms)
• Documented recurrent episodes of pericoronitis
• Occurrence of cellulitis
• Abscess formation or untreatable pulpal/periapical pathology
• Active current periodontal disease due to the position of the third molar and its association with the second molar; periodontal charting required
• A pathological condition such as a dentrigerous cyst or other related pathology
• External resorption of the third molar or of the second molar that appears to be caused by the third molar
• A non-restorable carious lesion on a partially erupted third molar or a carious lesion on the distal of the second molar due to the position of the third molar

To avoid Service Authorization denials, please note the following:

• Omission of a portion of the above documentation will result in a Service Authorization denial
• Documentation should always be supplied by the provider who will be performing the extraction
• Documentation of clinical observations made by the provider in the patient's chart notes during the patient's examination may be included
• The requirements listed above need to be specific to the tooth/area affected and should be clearly identified
• To meet the documentation requirements, providers can submit clinical findings, the diagnosis, and a treatment plan along with a summary letter stating the patient's chief complaint. Letters submitted with this information should be signed by the provider, not office staff.
• Referral slips will not be accepted as clinical documentation. Referral slips lack specific, accurate and objective data and do not contain current documentation.

Following the above criteria enables PrimeWest Health to make a fair and accurate determination of medical necessity. Further, it allows us to better serve both our members and providers.

*Service Authorization requirements can be found on the DHS website.

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The following is an excerpt from the Centers for Medicare & Medicaid Services (CMS) Minnesota Learning Network (MLN) Matters article SE1101.

Please review your clinical documentation and billing practices. Ensure that your office staffs are aware of the correct use of codes and modifiers and of Medicare policy regarding chiropractic services coverage.

Numerous audits of claims submitted by chiropractors for Medicare payment have demonstrated a significant portion of the claims to have been paid inappropriately. Correct claim payment depends largely on providers complying with Medicare requirements for coverage, coding, and documentation of services they report to Medicare. The goal of this article is to translate published Medicare coverage and payment requirements for chiropractic services into a few practical tips for better Medicare compliance and lower measured payment error rate.

The most common errors noted by Medicare auditors of chiropractic service claims generally fall into three broad categories:

• Technical errors such as missing signatures, date of service on the claim not found in the record, etc.
• Insufficient or absent documentation that all procedure(s) reported were performed
• No documentation or insufficient documentation that all spinal levels of manipulation reported had been performed;
• No documentation that each manipulation reported related to a relevant symptomatic spinal level;
• Non-covered devices or techniques applied in performing manipulation.
• Insufficient or absent documentation that all procedures services were medically reasonable and necessary
• Required elements of the history and examination were absent;
• Treatment plan absent or insufficient;
• Treatment was "maintenance."

For the complete article and additional information, please refer to this article on the CMS MLN Matters web page.

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The Centers for Medicare & Medicaid Services (CMS) is implementing the new standard for Transaction 835 (Health Care Claim Payment/Advice) Version 5010A1 adopted under the Health Insurance Portability and Accountability Act (HIPAA). Providers/suppliers must transition to the new version on or before January 1, 2012.

CMS has made Medicare Remit Easy Print (MREP) and PC Print software available to providers/suppliers to enable them to view/print/download the electronic remittance advice in version 5010A1 in a human readable format. MREP and PC Print have been updated to include the latest enhancements. The user guides for MREP and PC Print are being updated as follows:

• The MREP User Guide is being updated to reflect the changes in the software related to the HIPAA 5010A1
• The PC Print User Guide is being updated to reflect the changes in the software related to the HIPAA 5010A1 version for ASC X12 Transaction 835
  

If you use MREP or PC Print, be sure to download the updated user guides for 835 version 5010A1 when they are available.

Please refer to MM7466 available on the CMS Medicare Learning Network (MLN) Matters web page for additional information.

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The eXchange, a Minnesota-based collaboration of health care related organizations, offers translated materials and resources for better health communication. Translated materials include vital documents (such as surgical consent forms) and health education materials (such as information about diabetes management, asthma, etc.).

Minnesota Health Care Programs (MHCP)-enrolled providers may download or print these translated materials form the eXchange and use them with patients with limited English proficiency. To access these materials, select the Translation Library link from the eXchange home page. When prompted, enter dhs (upper or lower case) as the login ID and password.

This information can also be found in Chapter 1, Requirements for Providers, of the PrimeWest Health Provider Manual.

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Effective October 1, 2011, authorization requirements for portable oxygen concentrators will change. With the exception of members noted below, authorization will be required for rental of a portable oxygen concentrator. A portable oxygen concentrator will only be authorized for members for whom PrimeWest Health has authorized out-of-state medical care requiring air travel. Authorization is not required for other oxygen equipment or for oxygen contents provided by contracted providers.

For PrimeWest Senior Health Complete (HMO SNP)* and Prime Health Complete (HMO SNP)** members, or where PrimeWest Health is secondary to Medicare coverage, authorization will not be required. However, PrimeWest Health will only provide reimbursement for one form of portable oxygen.

*PrimeWest Health's name for the Minnesota Senior Health Options (MSHO) program
**PrimeWest Health's name for the Special Needs BasicCare (SNBC) program for members with Medicare

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PrimeWest Health believes input from our network providers is critical to ensuring that our approach to managed care and health plan operations reflects the needs and attributes of our contracted providers.

Your thoughts and opinions matter to us and we take them quite seriously. Indeed, past comments and suggestions from providers have helped to shape many PrimeWest Health policies and processes. So, please take a few moments to complete our Provider Satisfaction Survey to help us serve you better.

The survey will be available through September 16, 2011. You do not need to include your name unless you would like us to contact you regarding an issue or comment you have.

Thank you for your time, interest, and support!

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PrimeWest Health-hosted
Lunch & Learn
Thursday, July 28, 2011
11 a.m. – 1 p.m. 

This lunch and learn for chemical dependency providers will address the following topics:

• Coding
• Billing
• Authorization process
• Rate reform
• Placement
• Contracting

Representatives from PrimeWest Health's Provider Services, Member Services, Claims, and Care Coordination departments will be available to answer questions and address concerns you may have.

Please join us on July 28; lunch will be provided. The meeting will be held at PrimeWest Health's main office in the large conference room located at:
PrimeWest Health
2209 Jefferson St, Ste 101
Alexandria, MN

Please RSVP by July 21, 2011, to Chelsey Rhoads via email to chelsey.rhoads@primewest.org or via phone call to 1-320-335-5267 or 1-888-588-4420 ext. 5267 (toll free). Feel free to include any specific topics or questions you would like addressed.

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Service End Date vs. Discharge Date
Regardless of the service date, PrimeWest Health will require chemical dependency providers to bill the service date as the date of discharge for all claims received on or after September 1, 2011. This requirement is in line with standard billing practices. The PrimeWest Health Notification of Services letter you receive will reflect the units and service dates approved by the assessor on the CPA form. The CPA form and notification letter will not include the discharge date; however, it must be included on the claim as the service end date.

Legislative Rate Reform Changes Effective July 1, 2011
The Centers for Medicare & Medicaid Services (CMS) and the 2009 Minnesota legislature (through Minnesota Session Laws, 2009, Chapter 79, Article 7, Section 13) mandated a statewide rate methodology for Consolidated Chemical Dependency Treatment Fund (CCDTF) payments, which is effective July 1, 2011. The new methodology includes a graduated reimbursement scale based on patients' level of acuity and complexity and performance add-ons. It replaces county-negotiated rates. The rate reform includes the following changes:

Coding Updates
The coding changes will affect outpatient treatment only. The following codes may be used simultaneously when billing:

• H2035 – Outpatient individual therapy
• H0005 – Outpatient group therapy

You can find an updated Chemical Dependency Coding Structure on the PrimeWest Health website.

Modifiers
The new modifiers will be used for service agreements but will not and cannot be used for billing PrimeWest Health. Your claims will get rejected if you try to submit the following modifiers:

• HA – Adolescent
• TG – High intensity (30 treatment hours/week)
• TF – Medium intensity (15 treatment hours/week)
• 52 – Low intensity (5 treatment hours/week)
• HH – Co-occurring mental illness
• U4 – Special population
• U5 – With medical services
• U6 – Parents with children
• U8 – With MAT dosing
• U9 – All other MAT drugs
• UA – Methadone plus (minimum 9 hours/week counseling)
• UB – All other MAT drugs plus (minimum 9 hours/week counseling)
• UC – Co-occurring mental illness with medical services

At this time, these are the only changes effective July 1, 2011. Additional changes may take place January 1, 2012. The extent of those changes is unknown at this time.

Please refer to Chapter 15, Chemical Dependency, of the PrimeWest Health Provider Manual for additional information.

NOTE: PrimeWest Health is hosting a Lunch & Learn for chemical dependency providers on July 28, 2011. Please return to the Provider Updates page for more information on the Lunch & Learn!

As of July 1, 2011, the Minnesota government has not reached an agreement on the State budget and has shut down until an agreement can be reached. As part of the shutdown, the health boards that issue and renew practitioners' licenses are closed.

Any PrimeWest Health practitioner who does not have an active license as of July 1, 2011, does not meet the contractual obligations of PrimeWest Health's Participation Agreement, Credentialing Plan, and Policies and Procedures and cannot provide services to any PrimeWest Health member. If a practitioner were to practice without a valid license, PrimeWest Health would be responsible for reporting the practitioner to the appropriate licensing board.

For specific language regarding this matter, please refer to Section 3: Obligations of Clinic and Clinic Practitioners of your Participation Agreement and the PrimeWest Health Credentialing Plan.

Please contact us for coordination of care when you provide HCH services for a member in either PrimeWest Senior Health Complete (HMO SNP)* or Prime Health Complete (HMO SNP)**. This will help ensure that the HCH services you provide don't overlap with services we may already be providing

PrimeWest Health is contractually obligated by both the Minnesota Department of Human Services (DHS) and the Centers for Medicare & Medicaid Services (CMS) to meet certain contract requirements for our enrolled Medicare and Medicaid members. These requirements may be different from those your clinic met to earn Minnesota Department of Health (MDH) HCH certification.

Specifically, the assessment, care plan, outcome measures, or disease management/chronic care improvement program processes your clinic uses may not meet or may overlap with PrimeWest Health's obligations for our PrimeWest Senior Health Complete and Prime Health Complete members. For example, PrimeWest Health members are assigned a county case manager who performs many required care management functions, including conducting a comprehensive assessment to develop an individualized comprehensive care plan.

Please call the Provider Contact Center at 1-866-431-0802 (toll free) for more information.

*PrimeWest Health's name for the Minnesota Senior Health Options (MSHO) program
**PrimeWest Health's name for the Special Needs BasicCare (SNBC) program for members with Medicare

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The governor and the Minnesota legislature have not reached an agreement concerning the state's biennial budget. If no agreement is reached, most state agencies will close and services will cease as of July 1. This includes health boards that issue and renew practitioners' licenses. At the direction of the Dayton administration, these boards have indicated that health care providers (including physicians, nurses, pharmacists, and any other licensed health care professional) will not be able to renew their licenses during a government shutdown. Any professional whose license expires during a shutdown will be considered by the licensing boards to be unlicensed and therefore unable to practice.

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Effective July 1, PrimeWest Health will be implementing an upgrade for all users of the provider web portal. To access the updated portal, all users will need to have a new user name and password set up by their web portal administrator. PrimeWest Health expects that once you receive your new user name and password, you will not have to set them up again.

PrimeWest Health sent out emails to all web portal administrators the week of June 13 asking them to set up all users with a new user ID and password by July 1.

If you are an administrator and have not received an email, please fill out the registration form available on our website. Once registered, you will receive a new user name ID and password along with instructions on how to access the new web portal. You will then be able to set up users for your facility. If you have any questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

If you are a provider and have not received an email with your new login information, please contact the web portal administrator at your facility.

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PrimeWest Health is nearing completion of the upgrade to our provider web portal. The upgrade is necessary to meet new Federal regulatory requirements around the 5010 billing form and impending ICD-10 regulatory changes.

Users will notice a new look to the web portal. We are excited about this upgrade because it provides us with future opportunity to add additional content we were not able to provide in the past!

The features for checking member eligibility and viewing remittances and authorizations have all been improved. You will also be able to use this as a tool for contacting PrimeWest Health's Provider Contact Center.

Within the next 1 – 2 weeks we will be sending email notification to all Administrative Users of our current system. This email will include a link to the new site as well as new user ID and password. As an administrator for the facility, the Administrative User will set up users within your facility.

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

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Application of Casts and Strapping
Effective January 1, 2011, application of casts and strapping no longer requires a Service Authorization. Additional information can be found in chapter 17, Rehabilitative Services, of the Provider Manual.

Evaluative, Therapeutic, and Rehabilitation Services
Effective January 1, 2011, the following Evaluative, Therapeutic, and Rehabilitation Services no longer require a Service Authorization. Additional information can be found in chapter 17, Rehabilitative Services, of the Provider Manual.

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http://www.pfizer.com/files/news/embeda_recall_031611.pdf

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In July 2010, PrimeWest Health notified providers of the spinal fusion codes that require authorization. In 2011, the Minnesota Department of Human Services (DHS) added two additional codes to this list: 22551 and 22552.

The current list of spinal fusion codes that require authorization is: 22532, 22533, 22534, 22548, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22800, 22802, 22804, 22808, 22810, 22812, 22551, and 22552.

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

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PrimeWest Health has recently been notified that some of our providers have experienced problems with faxes getting through to us.

If you have tried to submit your document through a designated fax line and it did not go through, you can try resending your fax through our main fax line, 1-320-762-8750. Please direct the fax to the attention of a specific destination (Claims, Contracting, Provider Appeals, etc.) and your fax will be routed to the appropriate individual.

Thank you for your patience while we address this issue.

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Effective January 1, 2011, PrimeWest Health will limit payment to one annual evaluation and management (E/M) service for new and established patients, not to exceed one per calendar year for members with Medicaid benefits. PrimeWest Health will follow the Minnesota Department of Human Services' (DHS) lead in respects to the allowed E/M codes below.

For more information, please see Chiropractic Services (Chapter 18) in our Provider Manual or call our Provider Contact Center at 1-866-431-0802 (toll free).

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Several vaccine administration Current Procedural Terminology (CPT) codes have been deleted for 2011, and, as a result, there has been a change in the allowable administration codes that should be used when billing Minnesota Vaccines for Children (MNVFC) vaccines.

CPT codes 90465 - 90468 are valid for dates of service through December 31, 2010. After this date, these codes are no longer valid. Beginning January 1, 2011, please use codes 90471 - 90474 or 90460 - 90461, depending on the service/vaccine provided.

For additional details on MNVFC vaccines, please see the latest information on the Minnesota Department of Human Services (DHS) website.

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PrimeWest Health recognizes that there are situations when it is not possible or appropriate to require C&TC providers to complete certain components of the C&TC screening as outlined in the Schedule of Age-Related Screening Standards. For example, it is not necessary to require a provider to complete a hearing screening for a child who already has a diagnosis of being deaf or a vision screening when the child has a diagnosis of being blind. However, further diagnosis and treatment for these conditions may be appropriate.

The information below lists the situations and documentation required for a provider to bill with the accurate referral code designating the service as a C&TC screening. Use the following billing guidelines for the situations below when the vision or hearing screening component(s) cannot be performed.

If the child is deaf or blind:

1. Make certain that there is an exact diagnosis in the child's file indicating the child is deaf or blind
2. Use this diagnosis on the C&TC claim in addition to the preventive health screening diagnosis

If the child is uncooperative or contraindicated (e.g., ear infection, pink eye):

1. Re-attempt the hearing or vision screening within 30 days
2. Wait to bill the C&TC screening until all components are completed
3. Bill using the two separate dates, if within the same month
4. If the screening crosses over to a new month, use the date the C&TC screening was finally completed

Please call our Provider Contact Center at 1-866-431-0802 (toll free) if you have additional questions.

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The Centers for Medicare & Medicaid Services (CMS) requires physician-owned hospitals to disclose to their patients the names of the physician owners and the names of immediate family members of the physician who have an ownership or investment interest in the hospital.

Physicians are required to disclose to their patients at the time of referral if they (or their immediate family members) have an ownership or investment interest in the hospitals to which they refer patients for treatment.

Providers that fail to disclose this information to patients may lose their provider agreements to participate in the Medicare program, and physicians who fail to disclose this information to patients may lose their hospital medical staff memberships. For additional details on this requirement, please see CMS MLN notice MM6306.

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Effective March 15, 2011, providers will be required to submit a National Drug Code (NDC) with all Not Otherwise Specified (NOS) J Healthcare Common Procedure Coding System (HCPCS) codes. NOS J HCPCS code services billed over $100.00 will be subject to evaluation and may require authorization for further processing.

Please use the individual field available on the 837 claim format to enter the NDC code when submitting your claim.

If you need further assistance or have questions regarding this change, please call our Provider Contact Center at 1-866-431-0802 (toll free) for assistance.

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Medicare Remit Easy Print (MREP) The Centers for Medicare & Medicaid Services (CMS) released a new version of the Medicare Remit Easy Print (MREP) software in January. The current version is compatible with Microsoft XP operating systems. Effective July 1, 2011, a modification to the software will allow for compatibility with Microsoft Windows 7 and Vista, in addition to XP operating systems. CMS hopes making the software compatible with multiple operating systems will increase its use among providers/suppliers for printing their electronic remittance advice (ERA) records.

MREP is a free, CMS-developed software that enables providers/suppliers to read and print Health Insurance Portability and Accountability Act (HIPAA)-compliant ERA, known as Transaction 835. MREP has been in place since 2005 and is continuously being enhanced based on requests/comments received from users.

You can learn more about Medicare Remit Easy Print on the CMS website. Information on the latest enhancements to MREP can be found by reading CMS' Medicare Learning Network (MLN) Matters article # MM7218.

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Effective January 1, 2011, all PrimeWest Health providers must only use oral interpreters approved and listed on the Minnesota State Registry List by the Minnesota Department of Health. PrimeWest Health will only reimburse for provision of face-to-face oral interpretation services by interpreters who are listed on the State Registry.

Effective January 1, 2011, PrimeWest Health is also implementing the Administrative Uniformity Committee (AUC) recommendation to use modifiers when billing interpreter services. Providers are not required to list the name of the interpreter on the claim; however, the name must be noted in the medical record to allow for review during site visit audits.

PrimeWest Health does not cover any of the following for the interpreter:

1. Travel time
2. Wait time
3. Mileage
4. No show/cancellations

Report one unit of T1013 per 15 minutes (at least eight minutes must be spent to report one unit). Use only the 837P or 837I formats to submit interpreter service claims Providers of oral interpretation services may visit the Minnesota Department of Health website to find out more information and to register for inclusion on the State Registry. For additional information, please call the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

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CL and 24-hour CL providers: please note that the criteria for 24-hour CL services have been revised. Changes effective January 1, 2011, will include the following:

• Medication management
• Minimum of 50 hours per month of CL services
• Dependency in at least two activities of daily living (ADLs) – dressing, bathing, grooming, walking, or eating.

Please see the Minnesota Department of Human Services (DHS) bulletin #10-25-11 for additional details on the changes to criteria.

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PrimeWest Health will be closed December 24, 2010, in honor of the Christmas holiday, and December 31, 2010, in honor of the New Year holiday. All other days, PrimeWest Health will be open during our normal business hours of 8 a.m.– 4:30 p.m.

The PrimeWest Health Web Portal will continue to be available on the days the office is closed in the event a provider needs to check member eligibility or claim status.

PrimeWest Health wishes you a safe and happy holiday season!

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Currently, a Basic Screening Survey (BSS) may be performed by a Collaborative Practice (CP) dental hygienist for the purpose of referring a Head Start child to a dentist or dental clinic to establish continued dental care. CP dental hygienists triage children, perform other dental hygiene services, and refer children with dental needs to a dentist.

Effective January 1, 2011, BSS will no longer be reimbursed by the Minnesota Department of Human Services (DHS). PrimeWest Health will continue to cover BSS according to our current guidelines.

CP dental hygienists must meet the following enrollment requirements:

1. Be licensed by the Board of Dentistry in the state in which they practice
2. Have a collaborative agreement with a licensed dentist that meets state requirements*
   
3. Bill for dental services within their scope of practice as authorized in their collaborative agreement

*PrimeWest Health requires a copy of the collaborative agreement and verifies the dentist's license before enrolling a dental hygienist.

Before beginning a dental service/procedure, verify member eligibility and available services. Providers will need to contact the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free) to verify PrimeWest Health benefits on the other limited services.

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Effective January 1, 2011, PrimeWest Health will limit payment to one annual evaluation and require prior authorization for any combination of chiropractic manipulative treatment codes in excess of 12 treatments per calendar year for members with Medicaid benefits.

For Minnesota Senior Care Plus (MSC+) members who have Medicare as their primary insurance (in which PrimeWest Health is not their source of Medicare), PrimeWest Health will continue to follow Medicare guidelines.

For more information, please see the Chiropractic Services chapter in our Provider Manual.

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Effective January 12, 2011, PrimeWest Health will begin following Minnesota Department of Human Services (DHS) requirements for billing frame repair.

When billing frame repair, use either code 92370, repair and refitting of spectacles, or 92371, repair of spectacle prosthesis for aphakia. These codes will not require any additional modifiers.

When submitting claims for a replacement frame (complete frame), continue to use code V2020 with the RA modifier. A dispensing fee may only be billed if you are replacing a complete set of glasses (lenses and frame).

Frame repairs submitted after January 12, 2011 using code V2020 with the RB modifier will be denied.

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The Centers for Medicare & Medicaid Services will be releasing a new version of the Medicare Remit Easy Print (MREP) software in January.

CMS developed this free software that enables providers/suppliers to read and print Health Insurance Portability and Accountability Act (HIPAA)-compliant Electronic Remittance Advice (ERA), known as Transaction 835. MREP has been in place since 2005 and is continuously being enhanced based on requests/comments received from users.

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PrimeWest Health's clearinghouse recently informed us of a rejection notice that may have affected your claim processing. A system issue was rejecting claims with the reason "Policy number not on file." This rejection was occurring even if the member identification number was included in the claim. These rejections started on October 25, 2010, and this issue was resolved on November 15, 2010. Claims that rejected for this reason will need to be resubmitted, as they were not received by PrimeWest Health.

Please check the rejection report from your clearinghouse. If you have received any of these rejections, please verify your claim included the member identification number and resubmit your claim. If you have questions, please call the Provider Contact Center at 1–866–431–0802 (toll free).

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Effective January 1, 2011, PrimeWest Health will require lead agencies to begin using the following Personal Emergency Response Services (PERS)/Lifeline service Healthcare Common Procedure Coding System (HCPCS) codes:

• S5160 – Emergency response installation and testing
• S5161 – Emergency response system service fee, per month (excludes installation and testing)
• S5162 – Emergency response system purchase only

Claims submitted for PERS/Lifeline services with codes T2028 and T2029 after January 1, 2011, will be denied. PrimeWest Health will be adjusting current Service Authorizations for PERS/Lifeline authorizations using the new PERS/Lifeline codes.

Note that PERS cannot be authorized for members for the same period as 24-hour customized living services.

Billing

• Use the 837P professional claim format to submit claims for PERS/Lifeline services.
• Claims with the new PERS codes do not require a description.

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

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Effective January 1, 2011, PrimeWest Health will begin following Minnesota Administrative Uniformity Committee (MN AUC) Best Practices regarding date span billing.

On a professional claim, service date spans should only be within the same calendar month. Multiple claims may be submitted for different dates within the same calendar month based on the provider's billing practices.

On an institutional outpatient claim, statement and service date spans should only be within the same calendar month. Observation, extended recovery, and emergency department services beginning before and completing after midnight are exceptions to this if performed during the same visit. Procedures beginning on one day and ending on another should be billed together.

This does not apply to an institutional inpatient claim.

Pharmaceuticals should be billed with the administration/dispensed date—not a span of dates.

Monthly equipment rental should be billed with the start date of the rental period only—not the span of days.

Equipment rented on other than monthly basis (e.g., daily rental of equipment) needs both "from" and "through" dates. Units of service should be reported as one per rental period unless the code specifically indicates "per day." These service date spans should only be within the same calendar month. Do not submit your claim until after the last day of rental on the claim.

Supplies should be billed with the purchase date and not the span of days. The only exception to this is for the following three durable medical equipment (DME) items or supplies that are allowed date spanning:

• Continuous passive motion devices
• Diabetic testing supplies (test strips and lancets); include modifier indicating if member is treated with insulin (KX) or without insulin (KS)
• Parenteral and enteral nutrition

Claims for the items listed above will be held until the future date and processed as a clean claim at that time.

Claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items other than those listed above should not be billed with span dates!

For Medicare cross–over claims, date-spanned claims will be accepted as long as Medicare allowed it for the service for which you are billing.

Please call our Provider Contact Center at 1-866-431-0802 (toll free) if you have questions or need additional information.

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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 (Form W-9)

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

On October 1, 2010, PrimeWest Health sent Public Health agencies an update about changing the way claims for T1002 HD (RN Visit Prenatal Assessment) are submitted. At the time, we were requesting that this service be submitted on the 837I format to follow Minnesota Department of Human Services (DHS) requirements.

After further research into this issue, we have determined that PrimeWest Health is not required to follow DHS' change on this requirement. This is because we consider T1002 HD a code for prenatal assessments done via telephone, while DHS interprets it as a code for skilled nurse visits, which are therefore required to be submitted on the 837I format.

Because PrimeWest Health does not consider T1002 HD a skilled nurse visit, T1002 HD claims can continue to be submitted in the 837P format.

Continue to bill face-to-face prenatal assessments as part of your home visits, as you have in the past.

We apologize for any confusion this may have caused.

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You may have recently had a claim for the 90662 code for influenza vaccine denied as not covered. This denial was incorrect if the date of service (DOS) was September 1, 2010 or later, as the Centers for Medicare & Medicaid Services (CMS) began allowing code 90662 on September 1, 2010. PrimeWest Health is reprocessing these claims, and you should see the correction come through on your next remit.

PrimeWest Health follows Medicare guidelines on influenza vaccines. Please review the latest vaccine codes that Medicare allows for the 2010 flu season. If you have questions about influenza vaccines, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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The Minnesota Department of Health (MDH) has streamlined and updated home care licensure and home management resources on its website. Please note that MDH has included home care licensure survey forms for Class A and Class F home care providers, which MDH surveyors will use beginning November 1, 2010. Please bookmark these pages for future reference.

• Class A Professional Home Care Agency
• Class B Para-Professional Agency
• Class C Individual Para-Professional
• Class F Home Care Provider
Home Management

Links to the Class A and Class F survey forms can be accessed from these pages by clicking on the Survey Forms link.

• Class A Survey Forms
• Class F Survey Forms

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This update is intended to provide clarification for providers who submit claims to PrimeWest Health for oxygen rental.

PrimeWest Health follows Medicare guidelines for the coverage of oxygen rental. Payment for monthly rental of oxygen equipment during a period of continuous use will be made for up to 36 months. The oxygen rental payment includes reimbursement for the equipment, oxygen contents, maintenance, supplies and accessories, and other services necessary for furnishing oxygen and oxygen equipment. After 36 monthly rental payments have been made for the oxygen equipment, monthly payments will cease. The supplier that furnishes the oxygen during the 36-month payment period must continue to furnish the oxygen equipment during any period of medical need for the remainder of the reasonable and useful lifetime of the equipment, which is normally five years. After the five–year reasonable useful lifetime of the equipment has been reached, if the beneficiary still needs the equipment (i.e., the beneficiary meets the medical necessity for the oxygen), a new capped rental period may begin.

After the 36–month rental payment period, the supplier can bill for and receive a monthly payment for furnishing oxygen contents. Please refer to National Government Services website for a listing of those codes that are billable after the 36-month rental period.

PrimeWest Health recently did an audit of oxygen rental claims going back to 2007 rental. If the 36–month rental cap was reached and payment continued, claims will be recouped for any rental beyond the 36-month maximum. Claims submitted for oxygen rental beyond the 36–month cap will be denied with EX code 76 – Benefit Exhausted.

To ensure reimbursement on your oxygen rental claims submitted to PrimeWest Health, we encourage you to follow the standards for claim submission. Please ensure that you are using the correct place of service (POS) code on your claims. POS on oxygen rental claims should be the location where the beneficiary is residing at the time he/she is receiving oxygen. If the beneficiary is residing in his/her home, the POS should reflect this. If he/she is residing in a Skilled Nursing Facility (SNF), use the appropriate code to indicate the type of SNF. A complete listing of POS codes can be found on the Centers for Medicare & Medicaid Services (CMS) website.

If you have questions on recent recoupments of your claims or general billing questions, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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PrimeWest Health is teaming up with Prime Therapeutic (our Pharmacy Benefit Manager [PBM]) to review claims that exceed established thresholds for controlled substances. If your patient falls into this category, Prime Therapeutics will send you a letter with the pertinent information about these medications and the number of prescriptions that have been filled.

PrimeWest Health recently sent out a sample copy of this letter. The correct address for the Minnesota Prescription Monitoring Program (PMP) is: http://pmp.pharmacy.state.mn.us. If you have any questions, you can call our Provider Contact Center at 1-866-431-0802 (toll free).

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Effective September 1, 2010, PrimeWest Health no longer covers tetanus and diphtheria toxoids vaccine code 90718. Use the preservative-free tetanus and diphtheria toxoids vaccine code 90714 for both preservative and preservative-free vaccine billing.

As a reminder, PrimeWest Health covers vaccines that are not covered by the Minnesota Vaccines for Children (MnVFC) program, paying the fee schedule rate plus an administration fee of $1.50. Do not use State-supplied vaccines for vaccines administered for non-covered MnVFC programs. Bill the appropriate administration and vaccine codes to PrimeWest Health; do not use the SL modifier.

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Institutional providers that currently bill Medicare using more than one legacy identifier in order to identify subparts of their facility are required to submit a taxonomy code on all of the claims they submit to Medicare.

Effective November 18, 2010, PrimeWest Health will also require these facilities to report taxonomy codes on their claims to PrimeWest Health. Taxonomy codes must be reported by these facilities whether or not the facility has applied for individual National Provider Identifiers (NPIs) for each of its subparts. Institutional providers that do not currently bill Medicare for subparts are not required to use taxonomy codes on their claims to Medicare or PrimeWest Health. The list of taxonomy codes is available on the Washington Publishing Company website.

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Effective November 8, 2010, PrimeWest Health will follow Minnesota Administrative Uniformity Committee (MN AUC) guidelines regarding frequency type 0XX5 type of bill code on 837I claims. Per the Late Charge Billing section of the Minnesota Uniform Companion Guide for the 837I Health Care Claim – Institutional Transaction:

Late charge billings (xx5) are not considered for processing in Minnesota, replacement (xx7) must be utilized. Should a covered provider submit a late charge bill using (xx5), the adjudication rules of the payer may result in denial of the claim as it should not have been sent.

Any institutional claim (UB04 or 837I) submitted to PrimeWest Health after November 8, 2010 with the type of bill code of 0XX5 will be denied. All late charge billings should be submitted with the type of bill code 0XX7 and should be submitted as a replacement claim with the late charges added to the previously submitted charges.

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Minnesota Department of Human Services' (DHS) bulletins #09–53–04 (September 2009) and #09–53–04C (June 2009) address DHS guidance on the Level of Care Utilization System (LOCUS) assessments for adults. This document offers a brief summary of these bulletins and how LOCUS affects PrimeWest Health.

LOCUS is part of a process to ensure that members receive the appropriate level of services necessary for recovery from mental illness. The LOCUS addresses the setting for delivering the service, the intensity of the service, and the modality of the service. The LOCUS includes the member's diagnostic assessment, functional assessment, level of care assessment, and a review of the member's history, responsiveness to prior treatment, current level of engagement in treatment, and recovery treatment. In addition, member safety, and risk of, and other influences and life situations relevant to determining the appropriate care for recovery must be included. Recommendations from a LOCUS may include the following:

• Inpatient, residential, or community-based setting
• Team or individual approach to therapy
• Availability of specialized care providers
• High, low, or maintenance level frequency of services

Beginning October 1, 2010, LOCUS will be required for some service types within the adult mental health system for admission, continuing stay, and discharge eligibility criteria. The services types are as follows:

• Intensive Residential Treatment Services (IRTS)
• Partial Hospitalization, Day Treatment
• Assertive Community Treatment (ACT)
•  Intensive Community Rehabilitative Services (ICRS)
• Adult Rehabilitative Mental Health Services (ARMHS)
  

The LOCUS is not required for providers of crisis services and inpatient services, although it may be used. Service alignment with a LOCUS should not be the only criteria for admission to a service; the provider's resources and capabilities must also be considered.

The LOCUS may be completed by a mental health professional or a mental health practitioner under the supervision and guidance of a mental health professional, preferably his/her clinical supervisor. Clinical supervisors must sign the actual completed LOCUS. Keep in mind the functional assessment domains as specified in MN Stat. sec. 245.462, subd. 11a, items 1 – 11, are still a requirement and a part of the eligibility requirements for IRTS; Partial Hospitalization, Day Treatment; ACT; ICRS; and ARMHS. After implementation of LOCUS on October 1, 2010, the severity rating scale that has been attached to the functional assessment will no longer need to be completed.

The LOCUS instrument is protected by Federal copyright law. You may download a PDF from www.communitypsychiatry.org and photocopy and use the instrument in this original form. Prime West Health's Mental Health Medical Director (Greg Thelen, MD), Utilization Review Manager, and Behavioral Health Manager and Care Coordinator have reviewed the requirements of LOCUS and its application to the mental health authorization process PrimeWest Health currently has in place. This process is outlined below and will be applied at PrimeWest Health until otherwise contracted by DHS.

• PrimeWest Health will only require notification for the service types listed above.
• PrimeWest Health will not review the LOCUS, but will be requiring the providers to follow the clinical tool requirements for completion, documentation, and clinical supervision as well as the requirements outlined in the DHS bulletins.
  

In the fall of 2011, PrimeWest Health will conduct a provider audit following National Committee for Quality Assurance (NCQA) standards to verify the appropriate utilization of the LOCUS tool for admissions and continued stays. Providers selected for the audit will be given timely notification.

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POS codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry, and PrimeWest Health recognizes these POS codes. You can view a list of these codes on the CMS website.

Please be sure to use the code that most appropriately reflects the location of the service provided. For example, if a PrimeWest Health member resides in a Skilled Nursing Facility (SNF), you should use POS code 31. Although the member lives in the SNF (it is his/her home), POS 31 more accurately describes the location of the member than POS code 12 (home).

If you have questions on POS codes or other claim submission requirements, please call the Provider Contact Center at 1-866-431-0802 (toll free).

It is expected that with reasonable care, eyeglasses should not need to be replaced due to loss or damage more than once in a two-year dispensing period. However, vision providers may dispense new eyeglasses, even though two years have not passed since the member's last pair was dispensed. PrimeWest Health members are able to obtain a second pair of eyeglasses within the two-year dispensing period without a Service Authorization as long as replacement criteria are met.

In addition to the current criteria for providing a member with more than two pairs of eyeglasses in a two-year dispensing period (criteria can be found in Chapter 20, Eyeglasses and Vision Care Services, of the PrimeWest Health Provider Manual), a Service Authorization is required for all members, including Prime Health Complete (HMO SNP)/(SNBC) members, before providing a member with more than two pairs of eyeglasses in a two-year dispensing period.

• If the eyeglasses are lost, broken, or damaged beyond repair, the eyeglasses will be replaced with an identical pair of eyeglasses, unless the identical frame is not available (in which case a different frame will be substituted). The dispensing provider must obtain a written statement from the member (or the member's caretaker) explaining why the glasses were broken, lost, or can't be repaired and must send a copy of this documentation to PrimeWest Health with the Service Authorization request.

Please refer to Chapter 20 of the Provider Manual for more information or call the Provider Contact Center at 1-866-431-0802 (toll free).

A replacement claim is a resubmission of an incorrectly paid claim due to a billing error or a third party payment. If your previous claim submission was paid or a portion of the claim was paid and you need to make changes, please follow the corrected claims instructions in Chapter 4, Billing Policy, of the PrimeWest Health Provider Manual.

To avoid a possible delay in claims processing, if you are resubmitting on a previously denied claim, you are not required to submit as a replacement claim; we encourage you to submit the corrected claim as an original claim.

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

Effective August 1, 2010, if a home care provider facility determines it is unable to continue providing care to a member, the provider must notify the member, the member's responsible party, and PrimeWest Health at least 30 days before terminating services. The provider must assist the member transition to another home care provider.

If the termination is a result of sanctions on the provider, the provider must give each member a copy of the home care bill of rights at least 30 days before terminating services (per Minnesota Session Laws, Chap. 352, art. 1, sec. 8).

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

The following additions will be added to the PrimeWest Health Service Authorization list effective October 1, 2010:

• Continuous blood glucose monitoring supplies – A9276, A9277, and A9278
  Authorization will be required for all of these items. PrimeWest Health will follow the same criteria as listed in the Minnesota Health Care Programs (MHCP) Provider Manual.

• Pneumatic compression devices – E0652
  Authorization will be required for this item. PrimeWest Health will follow the same criteria as listed in the MHCP Provider Manual.

Other changes

Effective immediately, PrimeWest Health has revised the authorization requirements for standard wheelchairs, manual hospital beds, and rollabout and transfer chairs.

• Standard wheelchairs – K0001, K0002, K0003, K004, and E1229
  Authorization is required after three months of rental and for all purchases.

• Manual hospital beds
  PrimeWest Health no longer requires authorization.

• Rollabout and transport chairs – E1031, E1037, E1038, and E1039
  Authorization is required after three months of rental and for all purchases.

PrimeWest Health will now review Service Authorization requests for adults 21 years of age and older for dental codes D9220, D9221, D9230, D9241, D9242, and D9248. Please see the Coverage Guidelines for Dental Codes for details.

Please take the necessary steps to ensure that Service Authorization requests initiated by you or your staff contain the documentation required. This will facilitate PrimeWest Health's ability to accurately adjudicate your request and better serve you and our members.

If you have questions, please contact Leah Anderson at 1-320-335-5272, 1-888-588-4420 ext. 5272 (toll free), or leah.anderson@primewest.org.

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PrimeWest Health recently mailed a letter to primary care clinics asking site managers to complete an online access and accessibility survey. As a reminder, you will need to complete the survey for each individual primary care clinic site.

The survey is available on the DHS website from August 2 - August 31, 2010. Please complete this survey before August 31, 2010.

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On June 30, 2010, ClearConnect ceased all business operations.

ClearConnect was one of the clearinghouses sending 837 files to PrimeWest Health. Availity purchased the business from ClearConnect, but Availity did not purchase the individual provider/client contracts. The transition for providers from ClearConnect to Availity is not automatic, and providers will need to re-enroll for both 837 and 835 transactions with Availity or another clearinghouse.

If you were using any of the clearinghouse services from ClearConnect and have not switched to Availity or another clearinghouse that works with PrimeWest Health, you will need to take immediate action to avoid interruptions to your accounts receivables. Please refer to Chapter 4, Billing Policy, of PrimeWest Health's Provider Manual for a complete list of clearinghouses that work with PrimeWest Health. Please note that if you do not take immediate action, in addition to experiencing a service interruption, you will also be out of compliance by not receiving your remittance advices electronically, according to MN Stat. sec. 62J.536.

If you have registered with Availity, please note that the 835 enrollment process is separate from the registration process. To enroll for 835 transactions, you will need to complete Availity's Multi-Payer Enrollment Form and fax it to them at 1-972-383-6450. If you have questions for Availity, please call their Client Services at 1-800-282-4548 (toll free).

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Drug screening tests reporting qualitative screenings to detect the presence of specific drugs or classes of drugs for routine work-related issues or testing related to chemical dependency (CD) treatment are not covered.

Treatment providers must structure their rate system and contract with their lead county or tribe using a bundled methodology. This means all non- room and board services provided to a PrimeWest Health member, either by a PrimeWest Health provider or an outsourced provider, must be cost-averaged into a single unit rate. PrimeWest Health and the Consolidated Chemical Dependency Treatment Fund (CCDTF) do not allow a la carte or detailed rate structures.

Indian Health Service (IHS) Tribal 638 Facilities

All covered services provided through a tribal 638 facility may be paid at either the IHS encounter rate or the applicable fee-for-service rate. Tribes may choose either payment rate for each separate 638 facility. A single facility's services will all be paid at the chosen rate.

Services provided at a tribal facility that is not an IHS 638 tribal facility are not eligible for the IHS encounter/visit rate. For billing and service coverage information, these facilities must refer to the chapter that corresponds to the service provided.

For additional information, please call the Provider Contact Center at 1-866-431-0802 (toll free).

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PrimeWest Health follows InterQual (IQ) criteria for continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) devices. The IQ criteria require that after the initial three months of use, before authorization for continued use, the member must have adhered to prescribed treatment for at least three months and have documented effectiveness.

Providers are required to provide verification of recipient compliance with treatment. Currently, if criteria are met, PrimeWest Health purchases the CPAP/BiPAP device for the member after the initial three months of use. Any rent paid will be deducted from the purchase price.

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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).

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.

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).

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).

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.

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)

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.

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).

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.

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.

• 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.

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).

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).

The survey is available on the DHS website from May 1 - May 31, 2010. Please complete this survey before May 31, 2010.

Chemical dependency (CD): Chemical dependency treatment for GAMC enrollees who were previously enrolled in PrimeWest Health will be covered under the Consolidated Chemical Dependency Treatment Fund (CCDTF). GAMC enrollees must use providers covered under the host county contracts to receive methadone treatment or other CD treatment services. Rule 25 assessments and placement authorizations (when the provider has a host county contract) done while the enrollee was a PrimeWest Health member will be honored under FFS.

There may be providers that participated in-network with PrimeWest Health that are not CCDTF providers. In these cases, the providers must also inform the GAMC enrollee that in order to retain public funding, the enrollee must transfer to a CCDTF provider.

Pharmacies: Work with prescribers and GAMC recipients to identify GAMC FFS covered products (GAMC FFS only covers drugs made by manufacturers who participate in the GAMC rebate program, which may differ from PrimeWest Health's drug coverage). Also work with prescribers and recipients to use preferred drug agents when appropriate.

Inpatient Hospital: For GAMC enrollees who are hospitalized prior to and remain hospitalized on or after April 1, 2010, PrimeWest Health will continue to be the payer that is billed for the stay. The member would show up as FFS in MN-ITS.

Please refer to DHS for MHCP Provider Updates as they become available.

PW_2010_197

Shadow billing is not a PrimeWest Health requirement. However, shadow billing is a Centers for Medicare & Medicaid Services' (CMS) requirement for any member in a skilled inpatient SNF stay who has his/her Medicare coverage through a Medicare Advantage plan.

When a PrimeWest Health MSHO member is in a skilled level of care, in addition to submitting your claims for the skilled stay to PrimeWest Health for reimbursement, Medicare requires that a shadow bill be submitted to CMS. This allows CMS to track the days and deduct them from the 100-day SNF benefit period.

Claims for shadow bills must be submitted to CMS on a monthly basis. Once a member falls below a skilled level of care, these claims no longer need to be submitted to CMS.

Claims for shadow bills must be submitted as covered with a condition code 04, signifying the resident has an HMO.

When a resident falls below a skilled level of care, bill the last claim as a 214 or 211, with a 04 discharge status code.

You can find additional information on CMS billing requirements on the CMS website.

*PrimeWest Health's name for this program is PrimeWest Senior Health Complete (HMO SNP)

Effective May 15, 2010, PrimeWest Health will require Home and Community Based Service (HCBS) and Elderly Waiver (EW) claims to be submitted without an individual rendering provider on the claim. The only exception to this requirement is for Personal Care Assistance (PCA) claims.

The individual rendering provider section of the claim should remain blank for all claims for HCBS and EW services, except for PCA claims. For electronic claims, the individual rendering provider section of the claim is Loop 2310B, Segment NM109; for Office Ally and paper claims, it is box 24.

Claims for HCBS and Elderly Waiver services should be billed with only the billing (facility) provider information, including the correct National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) in the billing section. For electronic claims, the billing section is Loop 2010AA, Segment NM103; for Office Ally and paper claims, it is box 33.

Claims received on or after May 15, 2010, with rendering provider information entered will be denied.

If you have questions on this change to claim submission, please call the Provider Contact Center at 1-866-431-0802 (toll free).

PW_2010_135

The Compliance Monitoring Division of the Minnesota Department of Health (MDH) and the Office of Emergency Preparedness released a memo on March 15, 2010, directed to Minnesota nursing homes concerning bed availability in the event of evacuation due to flood.

To learn more, you can go to the MDH web page on which this memo is posted or go directly to the memo.

Rural Workforce Development Funding Opportunity
The federal Office of Rural Health Policy (ORHP) announced a new funding opportunity focused around Rural Workforce Development. This one-time funding opportunity will support the development of rural health networks that focus on activities relating to the recruitment and retention of emerging health professionals (students and residents). The program seeks to support a range of different approaches to community-based training and can include a focus either singularly or collectively on professions such as medicine, nursing, pharmacy and other allied health professions.

Approximately 20 awards are expected. The deadline to submit applications is April 20, 2010. Eligibility requirements are:

1. The applicant organization must be located in a rural area or in a rural census tract of an urban county, and all services must be provided in a rural county or census tract. Determine eligibility: http://datawarehouse.hrsa.gov/RuralAdvisor. OR
2. The applicant organization exists exclusively to provide services to migrant and seasonal farm workers in rural areas and is supported under Section 330G of the Public Health Service Act (documentation of status as a Section 330G Migrant and Seasonal Farm Workers organization must be uploaded as Attachment 10). These organizations are eligible regardless of the urban or rural location of the administrative headquarters. OR
3. The applicant is a tribal government whose grant-funded activities will be conducted within their federally-recognized tribal area
   

For further information, go to www.grants.gov, then click on Find Grant Opportunities, Basic Search and type in the funding opportunity number HRSA-10-193. The Office of Rural Health Policy will hold a technical assistance call on Thursday, April 1, 2010 at 2 p.m. Eastern Time to assist applicants in preparing their applications. The toll-free number is (800) 369-1914. The Passcode is Workforce. The Technical Assistance call will be recorded and available for playback within one hour of the end of the call and will be available until April 11, 2010. The phone number to hear the recorded call is 866-378-7476.

For further information, contact the program coordinator: Christina Villalobos at cvillalobos@hrsa.gov or (301) 443-3590.

PW_2010_127

The billing requirements outlined below are effective for claims submitted on or after April 25, 2010.

Billing for members enrolled in PrimeWest Health Medicare-based programs

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

Billing for all other PrimeWest Health members

• Bill one claim, regardless of transfers (combine hospital claim[s] and mental health unit claim[s]).
• Use the hospital NPI only.
  

In all cases, the correct admit origin and discharge status should be used to indicate the internal transfer. PrimeWest Health Medical Administration should also be notified of the transfer.

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

PW_2010_116

The "E3" initiative is a statutorily-mandated set of three electronic health care transaction requirements that went into effect in Minnesota at various times in 2009. PrimeWest Health is compliant with all three elements of the initiative.

Electronic submission of electronic data interchange (EDI) claims became mandatory on July 15, 2009. Paper claims are permitted for billing only in rare instances. Please refer to MN Stat. sec. 62J536 at www.revisor.mn.gov/statutes/?id=62J.536 to determine if your claim meets the eligibility requirements for exemption from mandatory EDI submission.

The requirements for submitting extra diagnosis codes (more than 4 diagnosis codes per claim) are described below.

EDI claims
For electronic claim submission using the 837P EDI formats, enter all relevant diagnosis codes in the appropriate diagnosis placeholder fields in the EDI template. It is not permissible, and would be considered a Health Insurance Portability and Accountability Act (HIPAA) violation, to submit this data in a field not designated for its specific purpose. Notes or comment fields are not valid for submitting diagnosis information. All diagnosis codes submitted via EDI must be entered in Loop 2300, Segment HI in order to be compliant.

Please check with your individual EDI clearinghouse to ensure their system allows additional diagnosis codes.

Paper claims
Effective with claims received on or after April 20, 2010, PrimeWest Health will no longer recognize additional diagnosis codes added to box 19 of the paper CMS-1500 claim form. Instead, additional diagnosis codes must be submitted as attachment information, following PrimeWest Health's instructions for indicating and submitting attachments via electronic means. Please review Chapter 4 of our Provider Manual for instructions on submitting attachments.

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

PW_2010_111

PrimeWest Health allows vision care providers to select eyewear for a PrimeWest Health member from any optical laboratory the provider normally works with. Vision care providers are not required to work with any specific State-contracted laboratory in order to serve PrimeWest Health members.

Providers must bill PrimeWest Health their usual and customary charge for their services. PrimeWest Health will pay the amount billed or the maximum allowable, whichever is lower.

PrimeWest Health has always required notification of inpatient admissions, including swing bed admissions. Effective March 15, 2010, PrimeWest Health will require electronic submission of the Swing Bed Notification Form. The Swing Bed Notification Form replaces the existing MSHO Communication Form. The Swing Bed Notification Form must be submitted electronically through the PrimeWest Health website before a member transitions from acute care to swing bed status. Eligibility should be verified before services are rendered and as needed after that.

PrimeWest Health will only apply Medicare Swing Bed Admission Criteria to determine swing bed medical necessity; however there may be additional questions on the Swing Bed Notification Form and all blanks on the form must be completed. All Swing Bed Notification Forms will be reviewed on a retrospective basis to ensure appropriate swing bed utilization. Failure to meet Medicare Swing Bed Admission Criteria may result in non-payment. A Service Authorization does not guarantee payment if medical necessity is not met.

SUBMITTING THE SWING BED NOTIFICATION FORM
Critical Access Hospitals ONLY

• Online
  The Swing Bed Notification Form will be located on the PrimeWest Health website at https://www.primewest.org/apps/swingbedauditform. This form should be filled out online and submitted to PrimeWest Health using the "submit" button. Please note, this form will not be available until March 15, 2010.

UPDATING SNF BED AVAILABILITY
SNFs ONLY

• Online
  For SNFs, PrimeWest Health will provide the SNF Bed Availability site at http://www.primewest.org/apps/snfbeds/snfbedsadmin/. PrimeWest Health will send your facility a login to use when updating your facility's SNF bed availability. For instructions on how to update your facility's SNF bed availability, visit our "How-to" on the PrimeWest Health website at http://www.primewest.org/apps/HowTo/UpdateSNFBedAvailability.aspx. Please note, the SNF Bed Availability site will not be available until March 15, 2010.

SPECIAL NOTE: PrimeWest Health care coordination staff members are available to help with any questions regarding transition from inpatient to swing bed status. Prompt notification of a pending or planned change in member status from inpatient to swing bed will help the process and ensure that members receive appropriate and necessary care. If you would like assistance coordinating this transition of care, please call PrimeWest Health clinical administration staff at 1-866-431-0803 ext. 5204 (toll free), Monday – Friday, 8 a.m. – 4:30 p.m. If you call after normal business hours, leave a message and a care coordinator will return your call as soon as possible.

Effective March 1, 2010 PrimeWest Health will be following DHS and will require telemedicine services (99499) to be submitted with the HK modifier. The HE modifier for these services will no longer be valid after this date.

Effective for dates of service beginning January 1, 2010, PrimeWest Health, following Medicare guidelines, will no longer recognize Current Procedural Terminology (CPT) consultation codes for office/outpatient settings (CPT codes 99241 - 99245) or inpatient consultation codes(CPT codes 99251 - 99255). This applies to Medicare-covered services only. Telehealth consultation G codes will not be affected by this change, and PrimeWest Health will continue accepting consultation codes for Medicaid-covered services.

For additional information, please refer to Medicare Learning Network (MLN) Matters article MM6740.

PrimeWest Health is following the Minnesota Department of Human Services' (DHS) code changes for Adult Mental Health Crisis Services.
Please see DHS provider update MHS-09-01 for additional information.

The Minnesota Department of Human Services (DHS) is offering a training video conference to answer questions and address concerns that prospective applicants have on the 2011 Community Services and Community Services Development (CS/SD) Request for Proposal (RFP). Click here to learn more.

Click here for more information.

(published in PrimePointers, January/February 2009 issue)

(PDF - PW_2010_026)

click here for more information.

Effective February 20, 2010, when a PrimeWest Health member leaves the hospital against medical advice (AMA) within the initial hours after an inpatient hospitalization admission, any services that have been provided to the member should be billed as outpatient services.

Please refer to chapter 13 of the PrimeWest Health Provider Manual for additional information.

Please keep the following in mind when submitting fitting codes (dispensing fees):

• Fitting codes 92340 - 92342 should only be included on the claim when billing for a complete set of glasses (frame and two lenses)
• Claims for lenses only or replacement of frames (V2020 or V2025 with the RA modifier) cannot be billed with a fitting code 
• Fitting code 92370 should be used when billing for repair of frames (V2020 or V2025 with the RB modifier)

PrimeWest Health providers can now check eligibility using Emdeon Office (formerly WebMD) through the Emdeon clearinghouse. Through this service, providers can transmit and view information regarding PrimeWest Health member eligibility, including benefits and copay information. If your office would like more information on Emdeon products, please contact Emdeon at 1-866-369-8805 (toll free) or http://www.emdeon.com/.

PrimeWest Health is following the Centers for Medicare & Medicaid Services' (CMS) requirement for dispensing supplies or accessories. Per CMS:

Pursuant to MN Stat. sec 62J.536, the Minnesota Administrative Uniformity Committee (AUC) adopted standards for the Minnesota Uniform Companion Guide for the Implementation of the Health Care Claim Payment and Remittance Advice Electronic Transaction (the "Guide"). As part of the AUC standards, all providers in the state of Minnesota should prepare to receive remittance advices electronically by December 15, 2009. More information...

Please see the DHS provider update DEN-09-01 for dental coverage limitations and policy changes that are effective beginning January 1, 2010.

Effective January 1, 2010, porcelain crowns will no longer be covered

Effective January 1, 2010, anti-scratch coating for eye glasses will no longer be covered

The RP modifier has been discontinued as of 1/01/2009.

• Bill replacement frame or lenses using the appropriate frame or lens code with modifer RA.  Do not bill a dispensing code for repairs or replacement of just the frame or lenses.
• Bill repairs to frames using V2020 with modifier RB.
• Bill dispensing fees only for a complete set of frame & lenses.

There has been some confusion about what type of bill (TOB) PrimeWest Health requires on home health claims. The TOB is a 3-digit code which defines the type of facility, bill classification, and frequency.

• The second digit of the code, 3, indicates home health.
  

• The third digit of the code defines bill classification and is broken down as follows:
• 032x: Inpatient home health visits under a plan of treatment – 60 day episodic billing. For home health prospective payment system (HHPPS) claims, it indicates a request for anticipated payment (RAP).
• 033x: Outpatient home health visits
• 034x: Critical access hospital providers billing home care services

• The fourth digit notes the frequency. Possible fourth digit options are listed below:
• 0XX2: First claim in a series of continuous claims or interim billing. When submitting the first claim, the admission date field must be the same as the statement date.
• 0XX3: Continuous claim or interim billing
• 0XX4: The last claim or discharge claim
• 0XX7: A replacement claim
• 0XX8: Void

To ensure correct billing, please be sure to include the appropriate TOB according to the services that you are providing. If you have questions on home health billing TOB requirements, please call the Provider Services Contact Center at 1-866-431-0802 (toll free).

PW_2009_362

Based on a decision by the 2009 Minnesota Legislature, changes to the Personal Care Assistance (PCA) program affecting access, assessment, and authorization will go into effect January 1, 2010. All PCA service recipients who are not on a waiver program must be reassessed using the new criteria.
Providers are responsible for submitting the PCA referral form (DHS-3324P) to the lead agencies 60 days before the end of the service agreement. In addition, providers are responsible for coordinating changes to the PCA Care Plan with the PrimeWest Health member based on the new assessment.
Detailed information regarding the reassessment schedule, Service Authorizations, and links to multiple resources about the PCA 6-Month Reassessment Project can be found on the PCA page of the Minnesota Department of Human Resources (DHS) website or in DHS Bulletin #09-56-02.