Provider Participation Requirements – Rule 101

Rule 101 (MN Stat. sec. 256B.0644) establishes requirements for provider participation in PrimeWest Health. In order for a provider to be reimbursed for other State-sponsored health care programs, the provider must accept, on a continuous basis, new patients who are members in these programs.

Other State-sponsored health care programs include the following:

  1. State employees’ health insurance plans
  2. Workers’ compensation insurance
  3. Public employees’ insurance program
  4. Health insurance plans offered to local statutory or home rule charter city, county, and school district employees

PrimeWest Health uses the Current Procedural Terminology (CPT) definition of a new patient: “A new patient is one who has not received any professional service from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.” A member who changes from another payer source to PrimeWest Health eligibility is not a “new patient” simply because of that change.

Rule 101 Non-Compliance

If PrimeWest Health has reason to believe a provider is not in compliance with the participation requirements, PrimeWest Health will notify the provider. The provider will have 30 days to provide PrimeWest Health with evidence of participation compliance. After the response period expires, those who have not submitted evidence of compliance will be reported to the Minnesota Department of Human Services (DHS).

A provider who fails to comply with the requirements of Rule 101 will be excluded from State-sponsored health care programs. DHS provides lists of providers who comply with participation requirements on a quarterly basis to the State Departments of Commerce, Employee Relations, and Labor and Industry.

PrimeWest Health Caseload Limits

Non-dental providers may limit acceptance of new PrimeWest Health members if their Minnesota Health Care Programs (MHCP) recipient caseload is at least 20 percent of the provider’s annual active caseload.

Annual caseload is determined as follows:

  1. By calculating the total number of patient encounters that result in a billing during the most recent fiscal year; or, if provider enrollment is less than a year, by calculating the total number of patient encounters that result in a billing during the period between enrollment and the end of the fiscal year.
  2. By counting patient encounters for all service sites enrolled under the provider’s National Provider Identifier/Unique Minnesota Provider Identifier (NPI/UMPI). Only one patient encounter per patient per day may be counted regardless of the number of service sites involved in the patient’s care. Provider may count recipients receiving health services on a fee-for-service basis and through a managed care plan.

If at least 20 percent of a provider’s annual active patient caseload is and continues to consist of Minnesota Health Care Programs (MHCP) members, the provider may refuse to accept new PrimeWest Health members for the remainder of the provider’s fiscal year only after submitting patient encounter data to PrimeWest Health Provider Relations staff as outlined below. 

Providers wishing to limit acceptance of new patients must notify PrimeWest Health Provider Relations staff in writing at least 10 days before limiting the acceptance of new PrimeWest Health members. The notice must include the provider’s name, NPI, fiscal period, total number of patient encounters for the last fiscal year, and the total number of MHCP patient encounters. Fax this information to PrimeWest Health Provider Relations staff at 1-320-762-8750. Contact PrimeWest Health for additional information at 1-866-431-0802 (toll free).

PrimeWest Health Provider Relations staff will notify the provider in writing whether its notice to limit PrimeWest Health caseload has been accepted. This acceptance will be effective 10 days after the provider is notified by PrimeWest Health and will remain in effect for the remainder of the provider’s fiscal year.
If a provider wishes to continue limiting PrimeWest Health caseload, the provider must file a new notice each year. In addition, a provider who has a contract with PrimeWest Health must also notify DHS of its intention to limit acceptance of new PrimeWest Health members.

Dental providers located outside the seven-county metro area are not subject to the 10 percent MHCP caseload requirement in meeting the Rule 101 requirements and are not required to accept new MHCP recipients who are children with special needs. 

Dental providers located within the seven-county metro area are required to meet the 10 percent MCHP caseload requirements and accept MHCP recipients who are children with special healthcare needs.

For purposes of this provision, children with special health care needs are children under age 18 who meet the following requirements:

  1. Require health and related services beyond that required by children generally; or
  2. Have or are at risk for chronic physical, developmental, behavioral, or emotional condition, including:
    1. Autism
    2. Bleeding and coagulation disorders
    3. Cancer
    4. Developmental disabilities
    5. Down syndrome and other genetic disorders
    6. Epilepsy, cerebral palsy, and other neurological diseases
    7. Endocrinopathy
    8. Fetal alcohol syndrome (FAS)
    9. Immunodeficiency disorders
    10. Visual impairment or deafness
    11. Other conditions as designated by the commissioner after consultation with representatives of pediatric dental providers and consumers

 

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Updated_05/25/2021