Except for emergency services, out-of-plan providers must obtain prior authorization before providing PrimeWest Health-covered services. Requests for prior authorization of services provided outside of the PrimeWest Health network or by non-contracted providers in or out of state must include documentation establishing medical necessity and the unavailability of that service in Minnesota or in the PrimeWest Health network. PrimeWest Health-covered services provided to a Minnesota member by an out-of-state, out-of-plan-provider will be covered under the following circumstances:
- The services are medically necessary;
- The services are provided in response to an emergency while the member is out of the state and the provider is out of plan;
- The services are not available in network or by an out-of-state contracted provider, and the attending physician has determined medical necessity and obtained prior authorization from PrimeWest Health; or
- The services are required because the member's health would be endangered if he/she were required to return to Minnesota or to an in plan or in network provider for treatment.