Medical Necessity Criteria
Removal of Service Auth Requirements
Effective December 1, 2006, PrimeWest will remove the service authorization requirement for non-emergent C-sections, non-emergent hysterectomies, non-emergent spinal fusion, and tympanostomy tube insertion (PE tubes). Minnesota DHS added the requirement for service authorization of these procedures in the fall of 2005. Our records indicate that in the past year, PrimeWest has not denied any request for C-section, PE tubes, spinal fusion or hysterectomy. Therefore, PrimeWest believes our providers perform these services only when medically necessary, and the SA requirement is a time-consuming process that has not led to any cost savings or impacted the quality of care our members receive.
Since our contract with DHS requires that we review medical necessity and utilization of these services, PrimeWest will periodically perform audits of claims paid for these services. In the event that it is determined that medical necessity for the procedure was not met, PrimeWest will readjuducate the claim for the procedure. If during an audit, it is determined that your facility has performed these procedures and medical necessity is not present, your facility will be then be required to resume obtaining a service authorization before performing these procedures.
PrimeWest will follow DHS criteria for determining medical necessity. Conditions supporting medical necessity for each procedure are listed below. As long as your facility is performing one of these procedures for one of the reasons listed, a service authorization will not be required.
Tympanostomy Tubes (PE tubes)
Non-emergent Hysterectomy
Non-emergent Spinal Fusion
Non-emergent C-Section
These lists are not all-inclusive. It is expected that documentation in the medical record will support indication for the procedure.
Over the next few months, PrimeWest's Quality and Care Coordination Committee will be working to modify the service authorization requirement for elective outpatient high-technology imaging studies (PET scans, MRI, CT & nuclear cardiology) by identifying and disseminating evidence-based practices for these services. Once the State approves these evidence-based criteria, we will be able to remove the requirement for service authorization for these services. In the meantime, these services will require service authorization.
We appreciate your cooperation and assistance in helping PrimeWest meet our contractual requirements with DHS. If you would like to assist in the development of evidence-based criteria, please contact PrimeWest's Medical Director at 1-888-588-4420.