Billing

Inpatient
Outpatient
Minnesota Critical Access Hospitals (CAHs)

Inpatient

Inpatient Billing

Inpatient Admission Following Outpatient Services

If a member is admitted as an inpatient directly following outpatient hospital services (e.g., emergency department, ambulatory surgery, observation status whether or not a bed was used), the date and hour of the inpatient admission documented on the 837I claim format must be the date and hour outpatient services began. Code “99” (hour unknown) is not acceptable. Outpatient includes services provided in the emergency department, ambulatory surgery, radiology, and observation status whether or not a bed was used.

PrimeWest Health Coverage Ends During Inpatient Stay

PrimeWest Health generally approves member eligibility on a monthly basis. If a member’s coverage ends during their inpatient stay, bill the following:

Type of Bill (TOB) 111
Dates member is eligible for coverage only
Occurrence code 25 and date coverage is no longer available
Occurrence code 42 and date of discharge
Patient status 30

If the member later becomes retroactively eligible for the entire inpatient stay, replace the claim, entering the Statement Covers Period dates as the entire inpatient stay.

Fee-for-Service (FFS) and Managed Care Organization (MCO) Transition During Inpatient Hospital Stay

Effective June 1, 2016, if a member changes health plans or changes from fee-for-service (FFS) to a health plan while he/she is in the hospital, the effective date of the health plan enrollment is no longer dependent on inpatient admit or discharge dates.

The new health plan will be responsible for the services that are not related to the inpatient hospital stay beginning on the effective date of the enrollment. The same policy applies when a member changes from a health plan to FFS.

If a member’s coverage changes from FFS to PrimeWest Health during a hospital stay, bill FFS for the entire stay. If the member is transferred to another hospital after the PrimeWest Health enrollment effective date, bill PrimeWest Health for the transfer claim.

If a member’s coverage changes from PrimeWest Health to FFS during a hospital stay, bill PrimeWest Health for the entire stay. If the member is transferred to another hospital after the FFS enrollment effective date, bill FFS for the transfer claim.

Inpatient Admission Following Outpatient Services—for Discharge Date on or after October 1, 2015

Include outpatient services provided immediately before an inpatient admission on the inpatient claim regardless of discharge date. Please note that the definition of covered days changed as of October 1, 2015.

Covered days are equivalent to the room and board days. Report covered days with value code 80 regardless of the date of discharge. Outpatient services were and continue to be included on the inpatient claim when outpatient services occur prior to admission.

Use the following information to report inpatient admission following outpatient services date for discharge date on or after October 1 2015:

Outpatient days are no longer included in the covered days when the admitting hospital delivers outpatient services immediately prior to the inpatient admission.
Covered Days/Non-Covered Days
1. Include outpatient services on the inpatient claim when outpatient services occur prior to admission.
2. Do not count the day of discharge.
3. Do not include the outpatient days in the covered days count.
4. Covered days are equivalent to room and board days.
Admission Date: Report the actual admission date.
Procedure codes: Use ICD10-CM procedure codes for the date service was rendered

Outpatient Services Treated as Inpatient Services

All services other than ambulance and maintenance renal dialysis services provided by the hospital (or an entity wholly owned or wholly operated by the hospital) and provided on the same date of the inpatient admission are deemed related to the admission and are not separately billable. Also, services provided on the first, second, and third calendar days preceding the date of admission are related to the admission, and thus must be billed with the inpatient stay, unless the hospital attests to specific non-diagnostic services as being unrelated to the inpatient hospital claim (that is, the preadmission non-diagnostic services are clinically distinct or independent from the reason for the admission) by adding a condition code 51 to the separately billed outpatient non-diagnostic services claim. Effective April 1, 2011, providers may submit outpatient claims with condition code 51. Refer to Laboratory/Pathology, Radiology, and Diagnostic Covered Services regarding billing of diagnostic services. All diagnostic services provided to a PrimeWest Health member on the date of the member’s inpatient admission and during the three calendar days immediately preceding the date of admission would continue to be required to be included on the bill for the inpatient stay.

Preventive Screenings

Screening services when provided to hospital inpatients should be billed using 12X TOB and will be paid at outpatient payment methodology.

Interim Billing

Inpatient hospital billing cannot be submitted until the member is discharged. However, for lengths of stay over 30 days, hospitals may submit replacement claims each month after the initial bill incorporating the previously billed/paid stay. Interim bills must include the Discharge Hour 99 and Patient Status Code 30, still an inpatient. If one or more interim payments have already been made, the original claim number of the claim being replaced must be entered in the Original Reference Number field of the claim format.

Inpatient Stays Exceeding 180 Days

Payment for claims with long lengths of stay will not be determined by length of stay, but by the regular DRG payment plus a cost outlier add-on, when eligible.

Deliveries and Births

Submit separate claims for a mother and her newborn. Newborns whose mother is enrolled in a health plan at the time of birth will be retroactively enrolled in the same health plan for the birth month, unless the newborn meets an exclusion.

Rehabilitation

Submit separate claims for members with admissions to a Medicare-designated rehabilitation unit, using the provider NPI number. Service Authorization must be sought for rehabilitation admissions. If a member is transferred between acute inpatient care and inpatient rehabilitation, each rehabilitation admission requires a different Service Authorization number, unless the rehabilitation admissions are to be combined.

If the admissions to a Medicare-designated rehabilitation unit are not issued separate Service Authorization numbers by the medical review agent, indicate the days in the acute inpatient setting as leave of absence days. Similarly, if the admissions to acute inpatient are not issued separate Service Authorization numbers or do not meet criteria for separate payment, indicate the days in the rehabilitation setting as leave of absence days.

For example, a member is admitted to an acute inpatient hospital, transferred to the rehabilitation unit, readmitted into the acute inpatient hospital, and is readmitted to the inpatient rehabilitation unit a few days later.

If the admissions meet criteria for two acute inpatient payments, the provider must bill separate claims for each acute inpatient hospitalization with each hospital’s PrimeWest Health provider ID number; and
If the medical review/utilization management team did not issue a new Service Authorization number for the second admission to the inpatient rehabilitation unit, the provider must submit one claim for both inpatient rehabilitation hospitalizations, indicating dates of the second acute inpatient hospitalization as leave days with its own Service Authorization number and the hospital’s NPI.

Same Day Transfers

When a member is transferred from one facility to another facility before midnight of the same day, the condition code of 40 must be assigned to the claim or the claim will be denied.

The original provider must bill as follows:

Indicate “0” in Covered Days;
Insert condition code 40 to indicate the member was transferred from one participating provider to another before midnight on the day of admission; and
Ensure that the admission date and statement “from” and “through” dates are the same.

Respite Care

Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time for Medicare beneficiaries.

The total number of general inpatient care days and inpatient respite care days may not exceed 20 percent of the total days provided to a hospice recipient.

Incarcerated Members

When an incarcerated member is covered by other health insurance, the health care provider must bill that insurance before submitting the bill to the appropriate county or Department of Corrections (DOC) for reimbursement. If the member is enrolled in PrimeWest Health, claims for inpatient services should be submitted to the Minnesota Department of Human Services (DHS). This includes services provided in the following:

21 – Inpatient Hospitals
51 – Inpatient Psychology Facility
61 – Inpatient Rehabilitation Facility

The claim will deny. Call the Minnesota Health Care Programs (MHCP) Provider Call Center at 1-651-431-2700 or 1-800-366-5411 to report claims that denied because the member was enrolled in PrimeWest Health for the date of service. MHCP will replace and pay the claims through Fee-for-Service (FFS). PrimeWest Health will not pay for inpatient services while the member was incarcerated. Providers should contact the appropriate county jail or correctional facility regarding how to bill for any outpatient services that were provided.

Medicare Exhausted Benefits for Members with Dual Eligibility (Non-PrimeWest Senior Health Complete [HMO SNP] Members)

If a PrimeWest Health member has dual eligibility with Medicare and exhausts Medicare benefits during an admission, the hospital can be paid the greater of the Medicare payment, including deductible and coinsurance (Medicare beneficiary responsibility is paid by PrimeWest Health), or the payment less Medicare payment including deductible and coinsurance.

Do the following when Medicare Part A benefits are exhausted:

Submit the inpatient charges to PrimeWest Health as primary
Follow the Electronic Claim Attachments instructions in Adjustment Requests, Corrected/Replacement Claims, Attachments, and Coordination of Benefits (COB)
Attach the Medicare’s (Part A and Part B) explanation of benefits (EOB) for date of service(s) (DOS)
Write “Medicare Part A Benefits Exhausted” on top of Medicare EOBs

Spenddown

When members have a spenddown satisfaction date, inpatient claims must be submitted using the first date of eligibility (the spenddown satisfaction date) as the “from” date. The date of admission must contain the date of the member’s admission to the inpatient hospital.

Inpatient Certified Registered Nurse Anesthetist (CRNA)

A hospital must remove Certified Registered Nurse Anesthetist (CRNA) costs from inpatient rates and have separate payment made for CRNA services. Inpatient CRNA services are not separately billable for hospitals that choose to retain CRNA costs in their inpatient rates.

Bill separately on the 837P for enrolled CRNA services provided in an inpatient hospital setting by any of the following:

A CRNA who is independent or employed by a physician
A CRNA employed by a hospital
An entity or group not enrolled as a hospital that is billing CRNA services
A critical access hospital (CAH) that does not qualify for the CRNA billing exemption under Medicare Part B

Inpatient DRG

A diagnosis-related group (DRG) is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiatives. In general, a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.

Payment for inpatient hospital stays is made according to the terms in a provider's contract with PrimeWest Health; reimbursement is based on the DRG associated with the stay. Payment will be the lesser of billed charges for Medical Assistance (Medicaid) members.

LTC Hospital

Long-term care hospitals (LTCHs) are certified as acute care hospitals, but LTCHs focus on patients who, on average, stay more than 25 days. LTCHs specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home.

PrimeWest Health processes all LTCH claims at the current rate on file at the time the claim is received. Payment is the lesser of billed charges for Medical Assistance (Medicaid) members.

Outpatient

Billing Instructions for Outpatient Claims

Bill outpatient hospital claims using TOB 13X or 14X.
CAHs must use TOB 14X for referenced or referred diagnostic services.
When attaching an Explanation of Medicare Benefits (EOMB), circle the member name related to the claim submitted on the EOMB.
Bill outpatient authorized services on a separate claim from non-authorized services.
Bill covered and non-covered services on the same claim.
When more than one clinic visit (distinctly separate E/M service) is provided, bill with condition code G0 on the same or separate claim.
Provider-based billing
1. Off-campus outpatient hospital
  1. 837I – use modifier PO for services, procedures, and/or surgeries performed at off-campus provider-based outpatient departments
  2. 837I – use modifier PN for non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
  3. 837P – identify the place of service (POS) with code 19
2. On-Campus Outpatient Hospital
  1. 837P – identify the place of service (POS) with code 22

See the Minnesota Critical Access Hospitals (CAH) section for billing instructions for CAHs.

Minnesota Critical Access Hospitals (CAHs)

Critical access hospitals (CAHs) are paid at a rate that is designated by CMS and based on each hospital separately. Payment for outpatient, emergency, and ambulatory surgery hospital services provided by a CAH as designated under MN Stat. sec. 144.1483 are made on a reasonable cost basis under the cost finding and allowable costs determined under the Medicare program according to MN Stat. 256B.75(b). Every fiscal year the rates change for the providers, but these rates can also change quarterly or monthly as well.

It is the provider’s responsibility to submit the Revised Payment and Retroactive Lump Sum Adjustment page along with the Critical Access Hospital Interim Rate Review page(s) to PrimeWest Health and update PrimeWest Health with any changes to the rates prior to the submission of the claims for that rate period. Once PrimeWest Health receives the updated rates, please allow up to 15 business 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.

Providers should email or fax all CAH rate updates and changes to PrimeWest Health at the following:

Email: claims@primewest.org
Fax: 1-320-762-1805

PrimeWest Health requires all CAH providers to fax or email CAH rates for claims processing on an annual basis. PrimeWest Health follows up with contracted CAH providers on a quarterly basis to verify their current CAH rate.

PrimeWest Health will process all CAH claims with the current rates on file at PrimeWest Health at the time the claim is received, regardless of participating or non-participating provider status with the PrimeWest Health provider network. If the current rates on file were received more than one year ago, claims will deny. Providers must send updated rates and resubmit the claim to be considered for reimbursement. PrimeWest Health processes all CAH claims at the current rate on file at the time the claim is received or the lesser of billed charges.

CAH Outpatient Interim Payment

For CAH outpatient services, valid TOBs are 851, 852, 853, 854, and 857. TOB 131 is not valid for CAH outpatient billing unless the CAH has been directed to use these codes by PrimeWest Health.

Requirements for HCPCS procedure coding and revenue code reporting follow Medicare guidelines.

The following revenue codes require a HCPCS code: 0250, 0260, 0274, 0300 – 0369, 0400 – 0449, 0460 – 0499, 0530 – 0549, 0610 – 0619, 0636, 0730 – 0759, 0771, 0920 – 0929, 0940, 0942, 96X, 97X, and 98X.

CAH Inpatient Payment

Payment for inpatient hospital is made according to the terms in your PrimeWest Health contract, generally at the most recent interim inpatient payment rates for your facility. If a member is admitted to a CAH as an inpatient from an outpatient department of the hospital (e.g., emergency department, ASC, observation status whether or not a bed is used), charges from the outpatient services must be included in the inpatient hospital stay. The date of admission submitted is the date outpatient services began.

CAH and Professional Services

A CAH must bill for outpatient professional services according to Medicare.

Unless instructed by PrimeWest Health to bill all professional services on the CMS-1500 form, a CAH that has elected under Medicare to bill for outpatient professional services in the UB-04 format (paper or electronic) instead of the CMS-1500 format (also known as Option Method II) must bill PrimeWest Health accordingly. The CAH must list the professional services along with the appropriate HCPCS code(s) (physician or other practitioner) and one of the following revenue codes: 96X, 97X, or 98X. Payment will be up to 100 percent of the PrimeWest Health physician fee schedule allowable before applicable reductions or adjustments.

A CAH that uses the standard method with billing to the Medicare carrier must continue to bill on the CMS-1500 format. Payment will be at the facility’s contracted rate, or up to 100 percent of the PrimeWest Health physician fee schedule allowable before applicable reductions or adjustments.

CAH and CRNA Services

CAHs will be paid for outpatient CRNA services according to Medicare.

A CAH that has applied and qualified for the CRNA billing exemption under Medicare Part B will be paid for such services by PrimeWest Health on a reasonable cost basis. Bill cost-based CRNA services in the UB-04 format (paper or electronic) using revenue code 0379 and no HCPCS procedure code.

A CAH that does not qualify for the CRNA billing exemption under Medicare Part B will be paid according to the PrimeWest Health fee schedule. Bill in the 837P format using the appropriate HCPCS code(s). Refer to Enrolled CRNA – Employee Billing in Physician and Professional Covered Services.

It is noted that the Medicare CRNA payment method may be different from the method elected by a CAH for inpatient services under PrimeWest Health. That is, a CAH may have elected to remove CRNA costs from its PrimeWest Health inpatient rates under MN Rules 9500.1105, subp. 1. A. (2) and have separate payment under the PrimeWest Health fee schedule.

PrimeWest Health requires Certified Registered Nurse Anesthetist (CRNA) exemption letters be provided in order for providers to receive the critical access hospital (CAH) rate for services provided.

CRNA exemptions letters can be submitted to PrimeWest Health at claims@primewest.org.

If PrimeWest Health has a current CRNA exemption letter on file for your facility, claims will pay with CAH rates. If PrimeWest Health does not have a CRNA exemption letter on file, claims will pay at current fee schedule rates. Once the CRNA exemption letter is received, it is the provider’s responsibility to resubmit any corrected claims in order to receive reimbursement.

CAH and Exhausted Medicare Benefits

If a CAH submits a PrimeWest Health inpatient claim because a member has exhausted Medicare Part A benefits but has billed Medicare Part B, use TOB 13X to submit Medicare Part B payment rather than 85X. The Part B services will be paid as a Medicare crossover under the Outpatient Prospective Payment System (OPPS) and offset against CMS inpatient payment.

CAH and Home Health Services

Medical Assistance (Medicaid)-covered home health services provided by a CAH are not paid based on a reasonable cost basis. Home health services continue to be paid under the PrimeWest Health fee schedule using TOB 341. Medicare-eligible home health episodes of care should be billed using the Home Health Prospective Payment System (HH PPS) billing guidelines as prescribed by CMS.

CAH and Chemical Dependency (CD) Services

Follow DHS substance use disorder services guidelines.

CAH and Ambulance Services

Ambulance services provided by a CAH or an entity that is owned and operated by a CAH are paid based on the reasonable cost basis.

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Updated_12/31/2025

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