Covered Services

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• Outpatient Physician-Administered Drugs
• Care Plan Oversight
• Education and Counseling
• Gender-Affirming Surgery
• Allergy Immunotherapy-Allergy Testing
• Enhanced Asthma Care Services
• Hyperbaric Oxygen Therapy
• Social Determinants of Health
• Surgical Services
• Telehealth
• Telemonitoring (Remote Physiological Monitoring Services)
• Transplant Services
• Medical Nutrition Therapy (MNT)
• Podiatry
• Anesthesia
• Family Planning
• Sterilization
• Hysterectomy
• Obstetrics and Gynecology (OB/GYN) Services
• Abortion-Related Services
• Home Birth

Services provided by a physician are not restricted to a specific place of service (POS) unless specified by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code description. Physicians may provide services in the member’s home, nursing home, outpatient hospital, inpatient hospital, or other facility.

Physicians may not bill separately for performing administrative or medical functions that are paid through an institution’s per diem rate.

A health service must be medically necessary in order to be a covered service. Services listed as provided by a physician in this section may be provided by other health care professionals if the service is within the scope of their practice as defined in Minnesota Statutes.

Outpatient Physician-Administered Drugs

Drugs that are administered to a patient as part of a clinic or other outpatient visit should be billed to PrimeWest Health using the appropriate HCPCS code(s). Do not bill drugs administered during an outpatient visit through the pharmacy point-of-sale system. PrimeWest Health does not allow “brown-bagging” (where a patient obtains a prescription drug from a pharmacy and takes it to a physician’s office to have it administered) or “white-bagging” (where a provider obtains a prescription drug from a pharmacy and then the patient visits the physician’s office to have it administered) of prescription drugs administered in an office setting.

Pharmacies, including mail order pharmacies, that are providing the drugs for a clinic visit, should bill the clinic and not PrimeWest Health for the drugs dispensed. PrimeWest Health will make an exception only if a member has third-party liability and the third-party payer requires that the drugs be billed through the pharmacy benefit. Pharmacies should not dispense drugs directly to a patient if the drugs are intended for use during a clinic or other outpatient visit.

For injections that involve multiple national drug codes (NDCs), bill the initial line with the HCPCS code and bill units and the first NDC with modifier KP (first drug of a multiple drug unit dose formulation). Bill the second, and any subsequent line item(s) of the same HCPCS code with modifier KQ (second or subsequent drug of a multiple drug unit dose formulation). If billing the same HCPCS code on more than two lines, the KQ modifier and an additional modifier are needed on each subsequent line.

Outpatient Physician-Administered Drugs National Drug Code (NDC) Reporting

The Federal Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for covered outpatient drugs administered by “physicians.” In order to comply, states must gather utilization data including the NDC, quantity, and unit of measure from claims submitted for physician-administered drugs.

Include the correct NDC information on all claims, including Medicare and other third-party claims, when billing non-vaccine drugs using HCPCS codes. Participants in the 340B Drug Pricing Program are included in the NDC reporting requirements; however, drugs purchased through 340B are exempt from NDC reporting. Add the UD modifier to drugs purchased through the 340B Program. Refer to the NDC Reporting Clarification when submitting claims for reimbursement.

NDC Reporting of Outpatient Physician-Administered Compound Drug

Enter one compound drug (HCPCS code) per claim transaction with up to 25 individual NDCs in the Drug Identification loop. The NDC quantity and dose form are reported in the Quantity and Unit or Basis for Measurement Code areas.

Multiple service lines are necessary to report a compound drug. One NDC is allowed per line. Report the HCPCS code as a separate line for each associated NDC.

Reporting the Discarded Portion of Administered Drugs

Report unused and discarded drugs on a separate claim line using the JW modifier. Providers are expected to use the package size that minimizes the amount of waste billed to PrimeWest Health. For example, if a member needs 50 mg of a drug, and the product comes in 50 mg and 100 mg vials, use the 50 mg vial unless the rest of the 100 mg vial will be used for another patient scheduled for treatment the same day. Both MHCP and Medicare encourage scheduling patients to make the most efficient use of the drugs administered.

Reporting the Wasted Portion of Administered Drugs

The submitted line should include the amount discarded with the amount administered. Providers are expected to use the package size that minimizes the amount of waste billed to PrimeWest Health. For example, if a patient needs 50 mg of drug and the product comes in 50 mg and 100 mg vials, providers should use the 50 mg vial unless the rest of the 100 mg vial will be used for another patient scheduled for treatment the same day.

Both PrimeWest Health and Medicare encourage scheduling patients to make the most efficient use of the drugs administered.

Authorization Requirements

Contact PrimeWest Health’s Utilization Management (UM) department when providing a physician-administered drug that requires authorization. All authorization requests will require a primary diagnosis and may require supporting documentation.

Evaluation and Management (E/M) Services

PrimeWest Health follows CPT guidelines for billing E/M services.

Concurrent Care

The provision of similar services (e.g., hospital visits to the same patient by more than one physician on the same day). If a consulting physician subsequently assumes the responsibility for a portion of patient management, it is considered concurrent care.

PrimeWest Health pays concurrent care when the medical condition of the member requires the services of more than one physician. Generally, a member's condition that requires physician input in more than one specialty area establishes medical necessity for concurrent care.

Non-Covered Concurrent Care Services

PrimeWest Health will not pay for concurrent care when either of the following occurs:

1. The physician makes a routine call at the request of the member and family or as a matter of personal interest
2. Available information does not support the medical necessity of concurrent care

Billing Concurrent Care

If the member's condition requires concurrent care, bill the appropriate E/M code and modifier.

Consultation

A consulting physician or qualified health care professional has a wide degree of latitude in providing services but does not assume care or provide treatment plans.

The request for consultation from the attending physician or other appropriate source must be documented in the member's medical record. The consultant's opinion and any services ordered or performed must also be documented in the member's medical record and communicated to the requesting physician.

If the consulting physician assumes responsibility for the continuing care of the patient, any subsequent services rendered will cease to be a consultation.

PrimeWest Health follows Medicare guidelines and does not recognize the following CPT consultation codes:

1. Office/outpatient settings (CPT codes 99241 – 99245)
2. Inpatient consultation codes (CPT codes 99251 – 99255)

This applies to Medicare-covered services only.

1. Medicare Advantage Plans
   1. Prime Health Complete (HMO SNP)
   2. PrimeWest Senior Health Complete (HMO SNP)

PrimeWest Health will continue accepting consultation codes for Medicaid-covered services.

Telehealth consultation G codes will not be affected by this change.

PrimeWest Health will allow claims submitted to PrimeWest Health as secondary where primary insurance was billed and paid.

1. If primary insurance denied as non-covered, provider must submit claim by PrimeWest Health rules.

Critical Care

Use CPT E/M codes to report critical care, which are designed to include both of the following:

1. All diagnostic and therapeutic services listed
2. Direction of care provided by the physician during the period for which this procedure code is billed

Follow CPT guidelines to determine which services are included in reporting critical care codes.

Physicians must not bill separately for procedures included in the code and performed during the critical care hour. Physicians may bill separately for services performed that are not included in the critical care codes.

Observation Services

Report E/M observation codes and follow CPT guidelines.

1. Observation services are covered with or without being preceded by a medical emergency.
2. Observation services are paid for up to 48 hours and, in some circumstances, up to 72 hours.

Physician Services While Member is Inpatient Status

For services or procedures done while the patient is considered in an inpatient status, use POS code 21 (inpatient).

Physician Services in Long-Term Care Facilities (LTCFs)

Payment for physician and professional services in an LTCF must be medically necessary. Refer to the Physician Extenders section for use of physician extender services provided in LTCFs. Refer to Long-Term Care for additional information on covered services in LTCFs.

Prolonged Physician Services

Prolonged services involving direct (face-to-face) patient contact are covered. Report the total duration of face-to-face time spent providing care on a given date.

Physician Standby Services

Standby services are covered when requested by another physician and involve prolonged attendance without direct (face-to-face) patient contact. Standby services are covered only in the case of a documented existing risk or distress, such as documented fetal distress.

Physician Case Management (Team Conferences)

A medical team conference conducted for the purpose of coordinating the activities of a member's care with an interdisciplinary team of health professionals or a representative of community agencies is a covered service.

The medical record must document the contents of the conference and the amount of time spent in the conference.

Bill the appropriate CPT E/M code.

Medical Conference/Counseling (as part of Evaluation and Management [E/M] code)

Physician services related to counseling are covered as part of the E/M codes if the counseling is conducted face-to-face with the patient, relative, or guardian.

When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter, time may be considered the key or controlling factor to qualify for a particular level of E/M service. Medical record documentation must reflect the content of the counseling, coordination of care, and the amount of time spent in counseling/coordination.

Telephone Calls

Telephone calls are not covered by PrimeWest Health.

Preventive Medicine Services/Counseling and/or Risk Factor Reduction

Preventive health counseling to promote health and prevent illness or injury is a covered service. These services should be billed with the appropriate E/M code for preventive medicine, individual counseling, and group counseling.

Smoking Cessation Services

PrimeWest Health covers smoking cessation education, counseling, and products when they are ordered by a primary care provider and provided by a PrimeWest Health-enrolled provider. Smoking cessation products must be approved by the Food and Drug Administration (FDA) and covered under the Medicaid Drug Rebate Agreement.

Medical Supplies Provided by a Physician’s Office

Eligible Providers

For the purpose of this section: physicians, APRNs, PAs, and physician clinics.

Payment Limitations

Payment limitations for medical supplies provided by a physician’s office are the same as for medical supplies. Refer to Equipment and Supplies. Routine supplies are not paid separately. Supplies applied or used in the physician’s office or clinic in direct relationship to an illness or injury are generally considered incident to the service and are not separately billable to PrimeWest Health.

Non-Covered Services

Supplies sent home with members are not covered by PrimeWest Health.

List of Routine Office Supplies

The following list of routine physician office supplies cannot be billed separately. This is not an all-inclusive list:

• Adhesive tape, all sizes
• Intravenous pyelogram (IVP) dyes
• Alcohol or peroxide, per pint
• Kerlix, Kling bandages
• Alcohol wipes
• Masks
• Autolet
• Micropourous tape
• Band-Aids
• Needles, sterile
• Betadine, Iodine, Providine swabs/wipes
• Opsite
• Betadine, Phisohex, per pint
• Patient electrode pads
• Chux pads
• Razor
• Cold packs
• Sanitary belt/napkins, tampons
• Cotton balls
• Silver nitrate stick
• Cotton tip application (sterile/non-sterile)
• Specimen collection
• Culturette
• Steri-strips
• Emesis basins
• Sterile saline, 30cc
• Enema kits
• Sterile water, 30cc
• Gauze pads, sterile or non-sterile
• Suction tubing
• Gelfoam
• Surgical drapes
• Gloves (latex, plastic, rubber, sterile, etc.)
• Suture removal tray
• Gowns
• Syringe (with/without needles)
• Hemostatic cellulose (e.g., surgical, any size)
• Thermometer (any size)

Electrocardiogram (EKG) Interpretations

EKG interpretation services may be billed in addition to the E/M service. PrimeWest Health covers one physician interpretation for each EKG.

Urgent Care Clinic Services

1. Urgent care clinic services are covered for PrimeWest Health members in an outpatient hospital setting.
2. Urgent care services in a freestanding facility (including physician clinics) must be billed as an office visit.

No facility fee is paid in a physician’s clinic for after-hours care.

Care Plan Oversight

PrimeWest Health encourages physicians to participate actively in care planning with our elderly members, their families, and our county partner case managers. PrimeWest Health understands that collaboration with county case managers and other team members takes added time. PrimeWest Health has approved the use of specific service codes pertaining to care plan oversight responsibilities and face-to-face visits with county case managers (patient not present). These codes and current rates are summarized in the following table.

Preventive Medicine Services

Preventive health services are covered if the service:

1. Is provided in person;
2. Affects a health condition rather than the physical environment;
3. Is not otherwise available to the member without cost as part of another preventive health program funded by a government or private agency;
4. Is not part of another covered service;
5. Avoids or minimizes an illness, infection, or disability that will respond to treatment (e.g., asthma or diabetes education);
6. Is generally accepted by the provider’s professional peer group as a safe and effective means to avoid or minimize the illness; and
7. Is ordered in writing by a physician, APRN, PA, and included in the plan of care approved by the primary care provider.

PrimeWest Health also covers Grade A and Grade B preventive services recommended by the United States Preventive Services Task Force.

Education and Counseling

Eligible Providers

Eligible providers include: enrolled physicians, physician clinics, community clinics, outpatient hospitals, public health clinics, family planning agencies, CNPs, PAs, CNSs, certified nurse midwives (CNMs), Community Mental Health Centers (CMHCs), and physician extenders. Certified asthma educators (CAEs) are eligible to provide asthma education.

Refer to the Community Health Worker (CHW) section for covered education services provided by a CHW.

Non-Covered Services

Services provided as part of a day treatment program, partial hospitalization, or other similar health care programs may not be billed as physician services provided in an educational or counseling setting.

Documentation

A physician order for educational or counseling services is required. Documentation of the member’s participation, number of participants in the educational or counseling group, name, and credentials of person who provided the service and topic content must be in the medical record or class record.

Billing

1. If an educational or counseling group is advertised as “free,” it cannot be billed to PrimeWest Health.
2. The cost of educational materials is included in the payment; no additional payment will be made for handouts, textbooks, or other materials.

Physician extenders must modify their services using the appropriate modifier. (Refer to the Physician Extenders section.)

Gender-Affirming Surgery

Overview

Gender-affirming surgery is considered medically necessary when a member has been diagnosed as having gender dysphoria and meets the established criteria. Treatment for gender dysphoria does not consist of a single procedure, but is part of a process involving multiple medical and surgical modalities.

Eligible Providers

Physicians enrolled with PrimeWest Health may provide and bill PrimeWest Health for covered services.

Eligible Members

All members enrolled with PrimeWest Health may be eligible for covered services.

Members must be age 18 or over to be eligible for phalloplasty.

Covered Services

PrimeWest Health covers the following services:

1. Hysterectomy and salpingo-oophorectomy
2. Vaginectomy (including colpectomy, metoidioplasty, phalloplasty, urethoplasty, and urethromeatoplasty)
3. Mastectomy, breast reduction, chest reconstruction
4. Penile prosthesis (noninflatable or inflatable)
5. Orchiectomy
6. Vaginoplasty (including colovaginoplasty, penectomy, labiaplasty, clitoroplasty, vulvoplasty, penile skin inversion, repair of introittus, construction of vagina with graft, and coloproctostomy)
7. Voice therapy (no authorization is required)
8. Electrolysis or laser hair preoperatively is covered and hair removal from the face, body, and genital areas for gender affirmation will be reviewed for medical necessity on a case-by-case basis that may include the following:
   1. Physician recommends hair removal prior to genital reconstruction for the treatment of gender dysphoria.
   2. Documentation explaining excessive hair growth and a letter from the clinician performing hair removal that supports the medical necessity of hair removal as it relates to gender dysphoria treatment.
9. Voice modification surgery is covered on a case-by-case basis when medically necessary. Provider must document medical necessity. An example is by recommendation of a voice therapist because voice therapy has had an inadequate reduction in vocal dysphoria, existing vocal presentation significantly varies from the normal for the gender, and vocal therapy has been exhausted.

Hormone therapy is not a pre-requisite for covered services unless otherwise specified.

In addition to these specific covered procedures, the following procedures may also be covered when medically necessary:

1. Breast augmentation surgery for male-to-female gender-affirming surgery is covered upon completion of 6 months of hormone therapy (12 months for adolescents) unless hormone therapy is medically contraindicated or not desired.
2. Scrotoplasty, testicular expanders, and testicular prostheses for female-to-male gender-affirming surgery
3. Facial surgeries may be considered for coverage on a case-by-case basis. Factors that may be considered in the case-by-case analysis include the following:
   1. How each requested procedure has a direct link to alleviating the documented symptoms of the gender dysphoria
   2. Documentation showing that no other physical or behavioral health condition could be causing the distress that the facial surgery attempts to address
   3. Explanation of how the symptoms will be alleviated through each requested procedure and how improvement will be measured and monitored

Noncovered Services

The following procedures are considered cosmetic and not medically necessary; therefore, in most instances these services are excluded from PrimeWest Health coverage:

1. Abdominoplasty
2. Blepharoplasty
3. Calf implants
4. Collagen injections
5. Electrolysis or laser hair removal unless other hair removal techniques on the site after surgery would be unsafe
6. Gluteal augmentation
7. Hair transplantation
8. Laryngoplasty
9. Lipofilling or collagen injections
10. Liposuction
11. Mastopexy
12. Neck tightening
13. Pectoral implants
14. Removal of redundant skin
15. Skin resurfacing (dermabrasion, chemical peels)
16. Trachea shave or thyroid cartilage reduction (chondroplasty)

Authorization Requirements

All gender-affirming surgery requires authorization. The member must meet the following criteria for the requested services before PrimeWest Health will authorize gender-affirming surgery:

1. Submit documentation supporting that the member has lived in the gender role that is congruent with their gender identity for at least 12 continuous months
2. Submit written referrals from clinicians qualified in the behavioral aspects of gender dysphoria. The referral letters must meet the following requirements:
   1. Genital surgery: A written referral from two independent clinicians with expertise in transgender health, one of whom has an established and ongoing relationship with the member.
      1. The referral letters may be from behavioral health professionals, the member’s treating provider (physician, nurse practitioner, clinical nurse specialist), or both.
      2. A referral letter from a behavioral health provider must include a recent diagnostic assessment.
      3. In the absence of a diagnostic assessment, the member’s medical provider (physician, nurse practitioner, or clinical nurse specialist) must complete a psychosocial assessment. Include the psychosocial assessmen components listed below.
   2. Chest surgery: A written referral from one clinician with expertise in transgender health and who has an established and ongoing relationship with the patient.
      1. If the referral letter is from a behavioral health provider, it must include a recent diagnostic assessment.
      2. If the referral letter is from the member’s treating provider (physician, nurse practitioner, clinical nurse specialist), a psychosocial assessment must be completed. Include the psychosocial assessment components.

Psychosocial assessment components

A psychosocial assessment must include the following:

1. Member’s current life situation
2. Age
3. Current living situation, including household membership and housing status
4. Basic needs status including economic status
5. Education level and employment status
6. Significant personal relationships, including the member’s evaluation of relationship quality
7. Strengths and resources including the extent and quality of social networks
8. Belief systems
9. Contextual non-personal factors contributing to the member’s presenting concerns
10. General physical health and relationship to member’s culture
11. Current medications
12. Reason for assessment
13. Description of symptoms including reason for referral
14. Perception of his or her condition
15. History of mental health treatment including review of records
16. Developmental incidents
17. Maltreatment or abuse
18. History of alcohol or drug abuse
19. Health history and family health history
20. Cultural influences and effect on diagnosis and possibly on treatment
21. Mental status exam
22. Assessment of the member’s need based on baseline measurements, symptoms, behaviors, skills, abilities, resources, vulnerabilities, and safety needs
23. Screening used to determine substance abuse and other standardized screening instruments (CAGE-AID, GAIN-SS)
24. Clinical summary
25. Prioritization of needed mental health, ancillary, or other services
26. Member and family participation in assessment
27. Referrals to services and service preferences by individual
28. Cause, prognosis, and likely consequences of symptoms
29. How the criteria for a diagnosis of gender dysphoria is met: symptoms, duration, and functional impairment
30. Strengths, cultural influences, life situations, relationships, health concerns, and how gender dysphoria diagnosis interacts with or affects member’s life
31. Primary diagnosis of gender dysphoria. If any other mental health or substance use disorders are present, make a referral to a mental health professional or a substance use treatment specialist

Clinician attestation

In addition to a diagnostic or psychosocial assessment, the referral letter must include the clinician’s attestation about each of the following:

1. The member’s general identifying characteristics
2. The duration of the referring provider’s relationship with the member, including the type of evaluation and therapy or counseling that the member underwent
3. An explanation that the member has met criteria for surgery and a brief description of the clinical rationale for supporting the request for surgery
4. A statement that the clinician obtained informed consent
5. A statement that the treating provider is available for coordination of care
6. Affirmation of gender dysphoria diagnosis
7. If significant medical or mental health concerns are present, documentation must support that these concerns are reasonably well controlled in addition to the member’s adherence to recommended medical and behavioral treatment plans. This includes the following:

1. Twelve months of continuous hormone therapy for genital surgery or twenty-four months of continuous hormone therapy for breast augmentation
2. Behavioral health therapy: member is receiving treatment, is in recovery, or is in stable remission of any co-morbid behavioral health conditions that are not attributed to dysphoria (e.g., psychosis, trauma, substance use disorder) for 12 continuous months. Stable remission is defined as lack of hospitalization, day treatment, or emergent care for any co-morbid behavioral health conditions during the 12-month period before surgery
3. No medical contraindications for surgery

Allergy Immunotherapy-Allergy Testing

Covered Services

The preparation of allergenic extracts and the administration of allergy immunotherapy are covered services.

1. Providing the raw pollen
2. Professional services to prepare raw antigen to a refined state that will become an allergenic extract
3. Professional services to administer the allergenic extract
4. Providing the injectable allergenic extract
5. Professional services to monitor the member’s injection site and observe for anaphylactic reaction
6. Allergy testing
7. Provision of inhalants (a pharmaceutical). Refer to Pharmacy.

Non-Covered Services

The following allergy testing and treatments have not been proven to be effective, and therefore are not covered.

Testing

1. Cytotoxic leukocyte testing (Brian’s test)
2. Leukocyte histamine release testing
3. Provocation-neutralization testing (sublingual, subcutaneous, intradermal, or intracutaneous)
4. Rebuck skin window test
5. Passive transfer or Prausnitz-Kustner (P-K) Test
6. Candidiasis hypersensitivity syndrome testing
7. IgG level testing general volatile organic screening test (volatile aliphatic panel)
8. Enzyme-linked immunosorbent assay (ELISA)/activated cell test (ACT) immunotherapy (Serammune Physician Lab, Reston, VA)
9. Antigen Leukocyte Cellular Antibody Test (ALCAT)

Treatment

1. Provocation-neutralization treatment (sublingual, subcutaneous, intradermal, or intracutaneous)
2. Oral and sublingual immunotherapy (includes oral drops, solutions, oral capsules, and tablets)
3. Rinkel immunotherapy (serial dilution endpoint titration). Note: Allergy testing using this method is eligible as a variant of conventional intradermal skin testing
4. Autologous urine immunizations
5. Clinical ecology urine immunizations
6. Candidiasis hypersensitivity syndrome treatment and related services
7. Intravenous (IV) vitamin C therapy
8. Enzyme potentiated desensitization
9. Rhinophototherapy
10. Poison ivy/poison oak extracts for immunotherapy
11. Trichophyton, Oidiomycetes, and Epidermophyton (T.O.E.) immunotherapy for chronic otitis media

Coverage Limitations

Allergenic extracts may be administered with either one or multiple injections. Documentation in the medical record must support the number of injections administered.

Preparation of Raw Antigen to Allergenic Extract: Only physicians who perform the refinement of raw antigens to allergenic extract may bill for this service. This service involves the following:

1. Sterile preparation of an allergenic extract by titration, filters, etc.
2. Checking the integrity of the extract by cultures or other qualitative methods

Purchasing refined antigens, measuring dosages, and adding diluent is not refining raw antigens.

Adding Diluent: As in any other medication administration, it is not a separately covered service. This service is an integral part of the professional services for providing an allergenic extract.

Additional Visits: Payment for injection administration will be adjusted and reflect monitoring of the injection site and observation of the patient for anaphylactic reaction.

A separate visit charge for the provision of allergy services is not allowed unless other identifiable services are performed such as physical examination, review of systems, obtaining a history of current symptoms or illness, laboratory services, and blood pressures, etc. Identifiable services not included in an office visit may be billed separately.

Enhanced Asthma Care Services

Enhanced asthma care services and related products provided in the home are covered for PrimeWest Health child members (i.e., members under age 18) with poorly controlled asthma. To be eligible for services and products, the child must meet the following requirements:

1. have poorly controlled asthma defined by having received health care from a hospital emergency department at least one time in the past year for asthma or have been hospitalized for the treatment of asthma at least one time in the past year; and
2. receive a referral for services and products from a treating health care provider

Eligible Providers

Asthma services must be referred and ordered by one of the following PrimeWest Health-enrolled treating providers:

• Physician
• Physician assistant
• Advanced practice nurse

The following may provide allergen-reducing products:

• Federally Qualified Health Centers
• Home health agencies
• Indian Health Services
• Medical suppliers
• Pharmacies
• Rural health clinics
• Public health nursing clinics
• Durable medical equipment providers

Other health care professionals, such as registered environmental health specialists, healthy homes specialists, lead risk assessors, certified asthma educators, and Public Health nurses, can make recommendations to PrimeWest Health-enrolled treating providers about allergen-reducing products for the child.

Once a written order has been given by an individual PrimeWest Health provider, a home assessment can be completed. A home assessment must be provided by one of the following credentialed local Public Health workers (local Public Health workers are not enrolled with PrimeWest Health):

• Healthy Homes Specialists defined and credentialed as a Healthy Home Evaluator by the Building Performance Institute
• Lead Risk Assessors as credentialed and defined by the Minnesota Department of Health (MDH)
• Registered Environmental Health Specialists as defined and credentialed by MDH

Covered Services

Covered services include home visits provided by a registered environmental health specialist or lead risk assessor currently credentialed by the Minnesota Department of Health (MDH) or a healthy homes specialist credentialed by the Building Performance Institute.

Covered products include the following allergen-reducing products that are identified as needed and recommended for the child by a registered environmental health specialist, healthy homes specialist, lead risk assessor, certified asthma educator, Public Health nurse, or other health care professional providing asthma care for the child, and proven to reduce asthma triggers:

1. allergen encasements for mattresses, box springs, and pillows;
2. an allergen-rated vacuum cleaner, filters, and bags;
3. a dehumidifier and filters;
4. HEPA single-room air cleaners and filters;
5. integrated pest management, including traps and starter packages of food storage containers;
6. a damp mopping system;
7. if the child does not have access to a bed, a waterproof hospital-grade mattress; and
8. for homeowners only, furnace filters.

A home assessment is a home visit to identify asthma triggers in the home and to provide education on trigger-reducing products. A child is limited to two home assessments; however, an additional home assessment may be performed if the child moves to a new home; if a new asthma trigger, including tobacco smoke, enters the home; or if the child's health care provider identifies a new allergy for the child, including an allergy to mold, pests, pets, or dust mites.

For more information on who is eligible to receive services, what is covered under the program, what is needed to get the services, and who can provide and bill for the services, review the DHS MHCP Asthma home evaluations and Allergen-reducing products for children FAQs.

Documentation

Counties are required to have a physician’s order and the order must be part of the member’s records.

Documentation in the member’s record must also include the name of the healthy homes specialist, lead risk assessor, or the registered environmental health specialist who completed the service.

Billing

Local Public Health workers and the Public Health agencies they work for cannot bill PrimeWest Health for home assessments because they are not PrimeWest Health-enrolled providers.

The following providers may bill for home assessments:

• Community Health Clinics
• County Human Services Agencies
• Federally Qualified Health Centers (FQHCs)
• Hospitals
• Indian Health Services
• Physician clinics
• Public health nursing clinics
• Rehabilitation centers
• Rural health clinics

Hyperbaric Oxygen Therapy

Covered Services

Prior authorization is not required for the specific diagnoses listed below.

Use of systemic hyperbaric oxygen therapy may be considered medically necessary and appropriate in the treatment of the following conditions:

1. Decompression sickness
2. Acute carbon monoxide/smoke/cyanide inhalation
3. Arterial gas embolism
4. Gas gangrene
5. Chronic refractory osteomyelitis
6. Necrotizing soft tissue infections
7. Crush injury with acute traumatic ischemia
8. Radiation necrosis
9. Compromised skin grafts or flaps
10. Non-healing diabetic wounds of the lower extremities when ALL the following criteria are met:
    1. Patient has type I or type II diabetes and a lower extremity wound due to diabetes; and
    2. Patient has a wound classified as Wagner grade 3 or higher
    3. Patient has no measurable signs of healing after 30 days of an adequate course of standard wound therapy
11. Thermal burns, acute (second and third degree)
12. Profound anemia with exceptional blood loss: only when blood transfusion is impossible or must be delayed
13. Pre- and post-treatment for patients undergoing dental surgery (not implant-related) of an irradiated jaw

Non-Covered Services

All other uses of systemic hyperbaric oxygen therapy are considered experimental/investigative due to a lack of evidence demonstrating improved health outcomes. Those conditions include, but are not limited, to the following:

1. Autism spectrum disorders
2. Bisphosphonate-related osteonecrosis of the jaw
3. Cerebral palsy
4. Herpes zoster
5. Acute ischemic stroke
6. Motor dysfunction associated with stroke
7. Traumatic brain injury
8. Vascular dementia

Social Determinants of Health

PrimeWest Health reimburses contracted providers $26 when they complete a social determinants of health (SDOH) assessment of a PrimeWest Health member. 

• PrimeWest Health members may have two assessments per calendar year. Assessments may be performed by contracted providers and county staff in PrimeWest Health’s service area.
• Assessments must be submitted using a PrimeWest Health-approved electronic format.
• Bill using 96160 with modifier SC
  • Claims submitted without the SC modifier will pay at the current fee schedule rate. When submitting claims with the SC modifier, providers are attesting that the electronic format has been shared with PrimeWest Health.

Surgical Services

Global Surgery Package

PrimeWest Health follows CPT guidelines regarding the global surgical package.

The global surgical package period: Surgery and the time following surgery during which routine care by the physician is considered postoperative and included in the surgical fee. Office visits or other routine care related to the original surgery cannot be separately reported if the care occurs during the global period. Global periods may be referred to as “follow-up-days” (FUDs).

PrimeWest Health covers medically necessary surgical services. PrimeWest Health reimbursement for all surgeries is based on a global surgery package, which follows Medicare global surgery guidelines and includes pre-, post-, and intraoperative work related to the surgical procedure. PrimeWest Health starts the global surgery the day of surgery and follows Medicare guidelines for the number of days in the global package. Preoperative physicals by a primary physician are not included in the global package. Evaluation of the need for surgery by the surgeon is also covered outside of the global surgical package.

The visit identifying the need for surgery is not included in the global fee even if occurring on the preoperative day or on the day of surgery. Use CPT modifier 57 to bill the E/M service for established patient visit or consultation the day before or the day of major surgery when the decision for surgery is made during the visit.

For global surgery purposes, surgeries are classified into three categories: exempt/endoscopic, minor, and major. The global surgery package for each category includes the following services.

Exempt/Endoscopic (0 days)

1. Physician visit on the same day as surgery
2. The surgical procedure
3. No postoperative days

E/M services provided on the same day as the procedure are generally not payable unless they are significant, separately identifiable, and billed with modifier 25.

Minor Surgery (10 days)

1. Physician visit on the same day as surgery
2. The surgical procedure
3. 10 days of postoperative care

E/M services provided on the same day as the procedure are generally not payable unless they are significant, separately identifiable, and billed with modifier 25.

Major Surgery (90 days)

1. Preoperative exam on the day of, or the day before surgery
2. The surgical procedure
3. 90 days of postoperative care

The visit identifying the need for surgery is not included in the global fee even if occurring on the preoperative day or on the day of surgery. Use CPT modifier 57 to bill the E/M service for established patient visit or consultation the day before or the day of major surgery when the decision for surgery is made during the visit.

Postoperative Care

Postoperative care includes:

1. E/M services
2. Pain management
3. Treatment of complications (e.g., treatment of infection related to the surgery)
4. Miscellaneous services: dressing changes and local incisional care; removal of operative pack, cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes/removal of tracheostomy tubes

Complications

Complications requiring additional services from the surgeon that do not require a return trip to the operating room are included in the global payment. Surgical complications requiring a return to the operation room are not included in the global fee. Report complications requiring a return trip to the operating room with modifier 78 appended to the original procedure code.

The following services are not included in the global package:

1. Initial (new patient) E/M visit
2. Diagnostic tests and procedures
3. Surgical trays
4. Recasting
5. Casting supplies
6. Dialysis
7. Immunosuppressive therapy
8. Radiation oncology services
9. Physical therapy (PT)
10. Silicone punctual plugs (A4263) when reported with code 68761 and POS code 11 (office)
11. Implantable vascular access device (A4300), when reported with code 36533 and POS code 11 (office)
12. Catheter used for treatment of a temporary obstruction and POS code 11 (office)

If further specifics are required, refer to the Medicare global surgery guidelines.

Assistant-at-Surgery

PrimeWest Health follows Medicare’s assistant-at-surgery guidelines. PrimeWest Health does not cover assistant-at-surgery services provided by surgical technicians, surgical assistants, Registered Nurse first assistants (RNFAs).

MD assistant surgeons or PAs are covered for assistant-at-surgery. MD assistant surgeons must bill using the appropriate assistant surgeon modifier. PAs, CNSs, and APRNs must use the “AS” modifier.

Billing

Submit claims for physician services at surgery electronically in the 837P format. Refer to Tribal and Federal Indian Health Services for physician services provided in an Indian Health Service (IHS), tribal, or 638 facility.

Bilateral and Multiple Procedure Modifiers

Please refer to the CPT guidelines regarding the appropriate use of modifiers.

Use modifier 50 only when the exact same service/code is reported for each bilateral anatomical site.

1. Report bilateral surgical procedure codes on one line appended with modifier 50.
2. Enter 1 unit on a line reported with modifier 50.
   1. Example: 49500 – 50 – 1 unit
3. Do not use modifier 50 with procedure codes that are identified as bilateral or for codes that use the words one or both within the code description.

Multiple Procedures – Modifier 51

For DOS on and after October 1, 2011, PrimeWest Health will do the following:

1. No longer require modifier 51 on multiple procedures performed at the same session, by the same provider, on the same patient
2. Deny procedures billed on subsequent claims for the same session, by the same provider, for the same patient
3. Price according to Medicare guidelines (highest valued procedure equals 100 percent; subsequent procedures equal 50 percent)
4. Not reduce pricing for procedure codes that are add-on codes or exempt from modifier 51

Bill all procedures on the same claim.

Telehealth

Telehealth is defined as the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site.

PrimeWest Health allows payment for the following services:

1. Interactive audio and video telecommunications that permit real-time communication between the distant site physician or practitioner and the member. The services must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face-to-face encounter.
2. "Store and Forward": The asynchronous transmission of medical information to be reviewed at a later time by a physician or practitioner at the distant site. Medical information may include, but is not limited to, video clips, still images, X-rays, MRIs, EKGs, laboratory results, audio clips and text. The physician at the distant site reviews the case without the patient being present. Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real-time.

Eligible Providers

The “spoke,” or referring provider, may be any enrolled PrimeWest Health provider, including the following:

1. Physician
2. NP
3. CNS
4. PA
5. CNM
6. Podiatrist,
7. Registered dietitian or nutrition professional
8. Clinical psychologist
9. Clinical social worker
10. Dentist, dental hygienist, dental therapist, advanced dental therapist
11. Pharmacist
12. Certified genetic counselor
13. Speech therapist
14. Physical therapist
15. Occupational therapist
16. Audiologist
17. Licensed Marriage and Family Therapist (LMFT)
18. Licensed Professional Clinical Counselor (LPCC)
19. Public Health nursing organization

The “hub,” or consulting provider, is limited to a specialty physician or an oral surgeon.

Originating site

The originating site is the location of an eligible PrimeWest Health member at the time the service is being furnished via a telecommunication system. Authorized originating sites include the following:

1. Office of physician or practitioner
2. Hospital (inpatient or outpatient)
3. Critical access hospital (CAH)
4. Rural health clinic (RHC) and Federally Qualified Health Center (FQHC)
5. Hospital-based or CAH-based renal dialysis center (including satellites)
6. Skilled nursing facility (SNF)
7. End-stage renal disease (ESRD) facilities
8. Community mental health center
9. Dental clinic
10. Residential settings, such as a group home, assisted living, shelter or temporary lodging
11. Home (a licensed or certified health care provider may need to be present to facilitate the delivery of telehealth services provided in a private home)
12. School
13. Correctional facility-based office
14. Mobile stroke unit

Telehealth Services

The CPT and HCPC codes that describe a telehealth service are generally the same codes that describe an encounter when the health care provider and patient are at the same site. Examples of telehealth services include but are not limited to the following:

1. Consultations
2. Telehealth consults: emergency department or initial inpatient care
3. Subsequent hospital care services with the limitation of one telehealth visit every 30 days per eligible provider
4. Subsequent nursing facility care services with the limitation of one telehealth visit every 30 days
5. End-stage renal disease services
6. Individual and group medical nutrition therapy
7. Individual and group diabetes self-management training with a minimum of one hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training
8. Smoking cessation
9. Alcohol and substance misuse (other than tobacco) structured assessment and intervention services

Covered Services

Coverage for telehealth includes payment for physician consultations that are performed via two-way interactive video or via store and forward technology.

Billing

Providers submitting professional claims for services rendered via telehealth must use claim format 837P (professional) and include the CPT or HCPCS code that describes the services rendered and the place of service 02 (when the member is not located in their home when receiving health services or health-related service through telecommunication technology) or place of service 10 (when the member is located in their home [a location other than a hospital or other facility where they get care] when receiving health services or health-related services through telecommunication technology). By reporting a service with place of service 02 or 10, providers are certifying that they are rendering services to a member located in an eligible originating site via an interactive audio and visual telecommunications system.

Modifier 93 must be included when billing for services provided via audio only (synchronous telehealth services rendered via telephone or other real-time interactive audio-only telecommunications system).

All other telehealth modifiers (GT, GQ, GO, 95) can be used for informational purposes, but are not required (note that the GT modifier is still required for critical access hospitals [CAHs] billing telehealth rendered via asynchronous telecommunication). If any telehealth modifiers are used without place of service 02 or 10, the claim will deny. For other types of billing, it is no longer required to identify telehealth.

General

1. Telehealth consultation coverage is limited to physician and non-physician services within their scope of practice. Refer to the eligible provider list above.
2. A consultation (as defined by CPT) must take place.
3. A request for a consultation and the need for a consultation must be documented in the patient’s medical record. The consultation opinion must be documented in the patient’s medical record and communicated to the requesting provider.
4. Consultations performed by providers who are not located in Minnesota and contiguous states require authorization prior to the service being provided.
5. Telehealth consultations provided by out-of-network physicians require a Service Authorization
6. All telehealth services must meet and follow Title 45 Code of Federal Regulations (CFR) Part 164.312 (e) (1):
   1. Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network
   2. Transmission security includes implementation specifications:
      1. Integrity controls (addressable)
      2. Encryption (addressable)
7. PrimeWest Health covers teledentistry claims for diagnostic services. Coverage is limited to children, pregnant people, and some adult benefits as specified in Minnesota Stat. 256B.0625, subd. 9. Bill using the U9 modifier.

Two-Way Interactive Video Consultations in an Office, Outpatient, or Inpatient Setting

1. Payment is made to both the consulting physician and the referring physician if the referring physician is present during the consultation.
2. The referring provider bills an office or outpatient E/M code.
3. The consulting physician bills an office, outpatient, or inpatient E/M consultation code, indicating the service was performed via two-way interactive video.

Two-Way Interactive Video Consultation in an Emergency Room (ER)

Two-way interactive video consultation may be billed when there is no physician in the ER and the nursing staff is caring for the patient at the “spoke” site. The ER physician at the “hub” site bills the ER CPT codes. Nursing services at the “spoke” site would be included in the ER facility code.

If the ER physician requests the opinion or advice of a specialty physician at a “hub” site, the ER physician bills the ER CPT codes. The consulting physician bills the consultation E/M code with place of service 02.

“Store and Forward” Telehealth

1. CPT definition of a consultation must be met.
2. Consultation E/M codes are billed by the consulting physician with the GQ modifier, used to indicate that the consult was done via store and forward technology.

Coverage Limitations

1. Payment will be made for only one reading or interpretation of diagnostic tests such as X-rays, lab tests, and diagnostic assessments.
2. Payment is not available to providers for sending materials.

The following are not covered under telehealth:

1. Electronic connections that are not conducted over a secure encrypted website as specified by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) Privacy & Security rules (e.g., Skype)
2. Prescription renewals
3. Scheduling a test or appointment
4. Clarification of issues from a previous visit
5. Reporting test results
6. Non-clinical communication
7. Communication via telephone, email, or fax
8. Day treatment
9. Partial hospitalization programs
10. Residential treatment services
11. Case management face-to-face contact

For more information on telehealth in the delivery of mental health services, refer to Mental Health Covered Services.

Telemonitoring (Remote Physiological Monitoring Services)

Telemonitoring services are the remote monitoring of data related to a member’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. Telemonitoring is a tool that can assist the provider in managing a member’s complex health needs.

Eligible Members

PrimeWest Health covers telemonitoring services for all members.

Eligible Providers

The assessment and monitoring of the health data transmitted by telemonitoring must be performed by the following licensed health care professionals:

• Advanced practice registered nurse
• Physician
• Physician assistant
• Podiatrist
• Registered Nurse
• Respiratory therapist
• A licensed professional working under the supervision of a medical director (e.g., an LPN)

Covered Services

PrimeWest Health covers telemonitoring services for members in high-risk, medically complex patient populations. These members have medical conditions such as congestive heart failure, chronic obstructive pulmonary disease (COPD), or diabetes.

PrimeWest Health covers telemonitoring services based on the following medical necessity criteria:

• The telemonitoring service is medically appropriate based on the member’s medical condition or status
• The member is cognitively and physically capable of operating the monitoring device or equipment, or the member has a caregiver who is willing and able to assist with the monitoring device or equipment
• The member resides in a setting that is suitable for telemonitoring and not in a setting that has health care staff on site
• The prescribing provider has identified and documented how telemonitoring services would likely prevent the member’s admission or readmission to a hospital, emergency room, or nursing facility
• The results of the telemonitoring services are directly used to affect the plan of care

Noncovered Services

Any service that does not meet medical necessity criteria will not be covered.

Billing

• Bill on 837P claim format (refer to the MN–ITS 837P Professional User Guides)
• Submit claims for telemonitoring services using the CPT or HCPC code that describes the services rendered.
• You must bill for at least 16 days of data collection within a 30-day period
• The data must be collected and transmitted rather than self-reported to the provider; the device must be defined by the FDA as a medical device
• Only MDs and practitioners may bill for remote patient monitoring (RPM) services
• Independent diagnostic testing facilities are not able to bill for RPM services
• Prior authorization is required

Transplant Services

Covered Services

PrimeWest Health coverage for organ and tissue transplant procedures is limited to those procedures covered by the Medicare program, approved by the DHS consulting contractor, or recommended by the State’s medical review agent. All organ transplants must be performed at transplant centers that meet United Network for Organ Sharing (UNOS) criteria and that are currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. Stem cell or bone marrow transplant centers must meet the standards established by the Foundation for the Accreditation of Cellular Therapy (FACT).

Types of transplants include the following:

1. Autologous pancreatic islet cell transplant (after pancreatectomy)
2. Heart
3. Cornea
4. Heart-lung
5. Intestine
6. Intestine-liver
7. Kidney
8. Liver
9. Lung
10. Pancreas
11. Pancreas-kidney
12. Stem cell

Transplant coverage includes: preoperative evaluation, member, and donor surgery, follow-up care for the member and live donor, and retrieval of organs, tissues. All transplant-related services are billed under the member’s PrimeWest Health identification (ID) number.

Eligible Providers

All organ transplants provided to Medical Assistance (Medicaid) members must be performed in a Medicare-certified transplant facility.

All transplant procedures must comply with all applicable laws, rules, and regulations governing the following:

1. Coverage by the Medicare program
2. Federal financial participation by the Medicaid program
3. Coverage by the Medical Assistance (Medicaid) program. All transplants performed out-of-state must have prior authorization.

It is the responsibility of the transplant center to submit their certification documentation to Provider Enrollment.

Eligible Members

Transplant coverage applies to all PrimeWest Health members. MinnesotaCare members should be referred to their county human services agency for application to Medical Assistance (Medicaid). If a member is not eligible for Medical Assistance (Medicaid), any maximum benefit limits applicable to the MinnesotaCare member will apply.

Authorization

Authorization is required for the following transplant procedures: stem cell, heart-lung, kidney, lung, pancreas, pancreas-kidney, intestine, intestine-liver, liver, heart, and autologous pancreatic islet cell transplant (after pancreatectomy).

The transplant prior authorization request must be submitted to PrimeWest Health Medical Administration by the physician rather than the transplant facility. The transplant facility may request documentation of the prior authorization approval from the physician’s office or by calling the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free). The medical report must include all of the following information:

1. Diagnosis, including ICD-10-CM diagnosis code
2. Proposed treatment
3. Sufficient, pertinent information

Out-of-state hospitals must include evidence of meeting the requirements of Medicare, UNOS, and FACT.

If a transplant is to be performed out-of-state, the provider must obtain authorization prior to the service being rendered.

Heart Transplant Coverage

Heart transplants must be performed at transplant centers meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. All heart transplants require authorization.

Artificial heart transplants are not covered.

Heart-Lung Transplant Coverage

Heart-lung transplants for people with primary pulmonary hypertension are covered when performed at transplant centers meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. Heart-lung transplants require authorization.

Lung Transplant Coverage

Lung transplants using cadaveric donors and lung lobe transplants from living donors are covered when performed at transplant centers meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. All lung transplants require authorization.

Kidney Transplant Coverage

Kidney transplants must be performed at transplant centers meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. All kidney transplants require authorization prior to the service being rendered.

Pancreas and Pancreas-Kidney Transplant Coverage

Pancreas transplants for uremic diabetic members of kidney transplants and people with hypoglycemic unawareness are covered when performed in a transplant center meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. All pancreas and pancreas-kidney transplants require authorization.

Liver Transplant Coverage

Liver transplants in children (under age 18 years) with extrahepatic biliary atresia or other forms of end-stage liver disease are covered.

Liver transplants are covered when performed at transplant centers meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104.

Liver transplants for children with a malignancy extending beyond the margins of the liver, or those with persistent viremia, are not covered.

Liver transplants using live donors are covered.

Liver transplants are covered for adults with the following conditions:

1. Primary biliary cirrhosis
2. Primary sclerosing cholangitis
3. Post-necrotic cirrhosis, hepatitis B surface antigen negative
4. Alpha-1 antitrypsin deficiency disease
5. Wilson’s disease or primary hemochromatosis
6. Alcoholic cirrhosis
7. Any other end-stage liver disease other than hepatitis B
8. Hepatocellular carcinoma
9. End-stage liver disease with the diagnosis of hepatitis B

In cases involving alcoholic cirrhosis:

1. The facility must state its criteria for the period of abstinence required prior to surgery;
2. The facility must include documentation that shows how the patient meets that criteria; and
3. The facility must include documentation showing evidence of social support to assure assistance in alcohol rehabilitation and immunosuppressive therapy following the surgery.

Liver transplants require authorization, including those covered by other third-party payers.

Intestine Transplant Coverage

Intestine transplants for a patient with a diagnosis of short bowel syndrome, parenterally dependent and experiencing life-threatening or potentially life-threatening complications due to the original disease or to complications of total parenteral nutrition (TPN), are covered. Intestine transplants must be performed in a transplant center meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104.

All intestine transplants require authorization.

Intestine-Liver Transplant Coverage

Intestine-liver transplants are covered for people who develop liver disease secondary to TPN treatment. Intestine transplants must be performed in a transplant center meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. Intestine-liver transplants require authorization.

Stem Cell Transplant Coverage

Stem Cell Transplantation: A procedure where stem cells are obtained from a donor’s or member’s bone marrow or peripheral blood and prepared for intravenous infusion. PrimeWest Health follows Medicare guidelines and is replacing references to bone marrow with stem cell transplantation.

Policy

Stem cell or bone marrow transplant centers must meet the standards established by the Foundation for the Accreditation of Cellular Therapy (FACT). All stem cell transplants require authorization.

Transplant centers must be participating providers of the Medicare program, meet Foundation for the Accreditation of Cellular Therapy (FACT) criteria for stem cell transplants, and be located in Minnesota or contiguous counties to receive payment for stem cell transplants

Allogenic stem cell transplants are covered for the treatment of leukemia, aplastic anemia, or myelodysplastic syndromes when it is reasonable and necessary for the individual patient to receive this therapy. Stem cell or bone marrow transplant centers must meet the standards established by FACT.

Allogenic hematopoietic stem cell transplantation for myelodysplastic syndromes is considered medically necessary for members who have prognostic risk scores of:

• Greater than or equal to 1.5 (Intermediate–2 or high) using the International Prognostic Scoring System (IPSS), or
• Greater than or equal to 4.5 (high or very high) using the International Prognostic Scoring System - Revised (IPSS-R), or
• Greater than or equal to 0.5 (high or very high) using the Molecular International Prognostic Scoring System (IPSS-M)

Autologous Pancreatic Islet Cell Transplant (After Pancreatectomy) Coverage

Autologous pancreatic islet cell transplant (after pancreatectomy) coverage is not to be confused with pancreatic islet cell allograft transplant (non-covered) for a member with a diagnosis of type 1 diabetes.

Pancreatectomy is covered for a member with a diagnosis of chronic pancreatitis with intractable pain. With pancreatectomy, the pain is relieved, but without the autologous pancreas islet cell transplant, the result is insulin dependent diabetes mellitus. The autologous pancreatic islet cell transplant has the potential to prevent diabetes or make the diabetes mild. This procedure is covered when performed in a transplant center meeting UNOS criteria and currently approved by CMS as meeting the CMS conditions of participation for transplant centers at 42 CFR 482.72 – 104. All autologous pancreatic islet cell transplants (after pancreatectomy) require authorization.

Billing Transplants

The cost of organ, tissue, and stem cell procurement should be included on the inpatient hospital claim. The hospital stay for the donor is included in the Diagnosis Related Group (DRG) payment for the donee (PrimeWest Health member). All charges for the donor should be billed using the donee’s PrimeWest Health ID number.

Other Payers

Liable third-party coverage monies must be used to the fullest extent before PrimeWest Health payment will be made for a transplant. If a third-party payer denies payment, the denial and documentation of efforts to secure payment must be submitted with the claim. If Appeals are available through the insurer, PrimeWest Health will ask the member to pursue these Appeals. Providers must obtain authorization for transplants that require authorization even though private insurance may pay a portion of the charges.

Medical Nutrition Therapy (MNT)

MNT is a preventive health service designed to assess and minimize the problems hindering normal nutrition, and to improve the patient’s nutritional status. MNT services may be provided in a physician’s office, clinic, or outpatient hospital setting. Medical necessity must be documented in the member’s medical record.

Licensed dieticians and licensed nutritionists may provide MNT and DSMT services for PrimeWest Health members when prescribed or referred by a physician.

The medical professionals who may prescribe/refer for MNT and DSMT services include: physicians, APRNs, CNSs, NPs, CNMs, and PAs. Providers should refer to in-plan licensed dieticians and licensed nutritionists. Contact PrimeWest Health to confirm that the provider you are referring to for MNT or DSMT is in PrimeWest Health’s network. (Out-of-network MNT or DSMT services will require Service Authorization prior to the service being started this will be granted on a case-by-case basis).

Eligible Providers

1. Licensed dietician
2. Licensed nutritionist

Licensed dieticians cannot enroll in PrimeWest Health independently.

Covered Services

MNT includes evaluation, follow-up, and/or group counseling prescribed by a physician. The medical necessity for these services must be documented in the medical record.

Weight Loss Services

PrimeWest Health covers physician visits, MNT, mental health services*, and laboratory work provided for weight management. Enrolled providers on a component basis with current CPT/HCPCS codes must bill services.

If a PrimeWest Health member elects to participate in a weight loss program, the member may be billed for components of the program that are not covered, as long as the member is informed of charges in advance.

Coverage standards for gastric restrictive surgery: See the Authorization Standards for Bariatric Surgery.

*Authorization may be required for mental health services. Refer to Mental Health Services for requirements.

Non-Covered Weight Loss Services

1. Weight loss services on a program basis
2. Nutritional supplements or foods for the purpose of weight reduction
3. Exercise classes
4. Health club memberships
5. Instructional materials and books
6. Motivational classes
7. Counseling or weight loss services provided by people who are not PrimeWest Health providers
8. Counseling that is part of the physician’s covered services and for which payment has already been made
9. Nutritional counseling for diabetic education when it is part of a diabetic education program (see the Diabetic Self-Management Training [DSMT] Services section).

Billing

PrimeWest Health reimburses dietician or nutritionist services listed only when prescribed by a physician and provided in an office or outpatient setting. MNT and DSMT are separate benefits and may not be billed for the same date of service. Payment for medical nutritional therapy provided by a licensed dietician (under the supervision of a physician) is limited to the following codes:

Dietician or Nutritionist Billing Guidelines for Rendering and Billing Providers’ National Provider Identifier (NPI)

If services are rendered somewhere other than the listed billing provider address or in the member’s home, include the service facility location’s name, address, and NPI/Unique Minnesota Provider Identifier (UMPI).

National Diabetes Prevention Program (DPP)

The National Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program designed by the Centers for Disease Control and Prevention (CDC). DPP is a year-long program intended for adults at high risk for developing type 2 diabetes. DPP includes lifestyle health coaching through weekly classes that teach skills needed to lose weight, become more physically active, and manage stress.

The program must include an initial six-month phase during which a minimum of 16 sessions are offered over a period lasting at least 16 weeks and not more than 26 weeks. Each session must be at least one hour long.

The second six-month phase must consist of at least one session each month. Each session must be at least one hour long. Additional sessions may be delivered if participants require additional support.

DPP may be provided in a clinic, outpatient hospital, or community setting. The covered code 0403T was effective January 1, 2016.

Organizations can use the curriculum available on the CDC website. If your organization chooses to use a different curriculum, send the curriculum to the Diabetes Prevention Recognitions Program (DPRP) to be evaluated to ensure that it is consistent with the current evidence base.

Eligible Providers

An organization must have full or pending CDC recognition as a DPRP to provide the National DPP to PrimeWest Health members. The CDC determines eligibility.

CDC-recognized organizations are responsible for training coaches to the 2012 National DPP curriculum or the Prevent T2 curriculum. DPP coaches may have credentials (e.g., RD, RN), but credentials are not required. Coaches do not need to enroll with PrimeWest Health.

Eligible Members

Members must meet all of the following requirements:

1. Be age 18 or over
2. Have a body mass index of greater than or equal to 24 (greater than or equal to 22 if Asian)
3. Have no previous diagnosis of type 1 or type 2 diabetes
4. Have at least one of the following test results within the past year:
   1. Hemoglobin A1C: 5.7 – 6.4%
   2. Fasting plasma glucose: 100 – 125
   3. Two-hour plasma glucose (after 75 gm glucose lead): 140 – 199 mg/dl
   4. Be previously diagnosed with gestational diabetes

Billing

Use only code 0403T for DPP (preventive behavior change, intensive program of prevention of diabetes using a standardized prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day).Do not bill nutritional counseling, evaluation and management codes, or other procedure codes when billing for DPP.

Diabetic Self-Management Training (DSMT) Services

DSMT is a preventive health service for people diagnosed with diabetes. A DSMT program includes education about self-monitoring of blood glucose, diet and exercise, an insulin treatment plan developed specifically for the patient who is insulin dependent, and motivates patients to use the skills for successful self-management of diabetes. DSMT services minimize the occurrence of disease and disability through instructions on maintaining health and well-being of the patient.

Eligible Providers

1. Diabetic care instructions may be provided by a physician or RN.
2. Nutritional counseling may be provided by a physician or licensed dietician. Referrals should be made to licensed dieticians for in-depth nutritional counseling.
3. Licensed RNs may only provide nutritional counseling to the extent that their scope of practice and education experience allow.

A provider of dually eligible PrimeWest Health members must be a “certified provider” according to Medicare’s definition. Certified providers for Medicare’s purposes must meet the National Diabetes Advisory Board Standards.

Covered Services

A physician must order all DSMT services. DSMT services include:

1. Diabetes overview
   1. Type of diabetes
   2. Blood glucose testing
   3. Blood glucose self-monitoring education
   4. Insulin treatment plan for patients who are insulin dependent
   5. Foot, skin, and dental care
2. Diabetes management
   1. Stress and psychosocial adjustment
   2. Family involvement and social support
   3. Medications, monitoring, and use of results
   4. Prevention, detection, and treatment of chronic complications
   5. Prevention and treatment of low and high blood sugar
   6. Benefits, risks, and management options for improving glucose control
3. Nutritional counseling
   1. Meal planning, carbohydrate counting, label reading
   2. Dietary fat and cholesterol modification
   3. Role of fiber on blood sugar and cholesterol control
4. Exercise and activity
   1. Relationships among nutrition, exercise, medication, and blood glucose levels
   2. Behavior change strategies, goal setting, risk factor reduction, and problem solving
5. Pre-conception care, pregnancy, and gestational diabetes
6. Use of health care systems and community resources

Billing

Use the appropriate DSMT codes below when billing. Do not bill nutritional counseling, office visit (E/M) codes, facility codes, or other procedure codes with DSMT codes.

Bill one unit per each half hour of DSMT services, with a maximum of not more than 10 hours within a continuous 12-month period for each member. After the initial 10-hour training, additional DSMT services are limited to one hour (group or individual) per year.

Nutritional Products

A nutritional product is a commercially formulated substance that provides nourishment and affects the nutritive and metabolic processes of the body. Nutritional products are covered by PrimeWest Health.

Eligible Providers

A parenteral nutritional product must be dispensed as a pharmacy service as prescribed by a physician. Refer to Pharmacy.

An enteral nutritional product may be supplied by a pharmacy, home health agency, or medical supply provider with a written physician’s order.

Covered Nutritional Services

PrimeWest Health covers enteral nutritional products when the member’s diagnosis can be linked to the need for a nutritional product. Refer to Equipment and Supplies for additional information.

Podiatry Services

Providers

Podiatrists who practice as defined in MN Stat. Chap. 153 and physicians are eligible for payment for podiatry services.

Covered Services

1. Debridement or reduction of pathological toenails, and of infected or eczematized corns and calluses
2. Avulsion of nail plate
3. Evacuation of subungual hematoma
4. Excision of nail and nail bed
5. Reconstruction of nail bed
6. Other non-routine foot care

Payment Limitations for Debridement or Reduction of Nails, Corns, and Calluses

Payment for debridement or reduction of non-pathological toenails, and of non-infected or non-eczematized corns or calluses is limited. These services are considered routine foot care, unless the patient has a systemic condition which may require the expertise of a professional.

Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular disease (with synonyms in parenthesis) most commonly represent the underlying conditions that may justify coverage for routine foot care:

1. Diabetes mellitus
2. Arteriosclerosis obliterans (ASO, arteriosclerosis of the extremities, or occlusive peripheral arteriosclerosis)
3. Buerger’s disease (thromboangiitis obliterans)
4. Chronic thrombophlebitis;
5. Peripheral neuropathies involving the feet associated with:
   1. Malnutrition and vitamin deficiency
      1. Malnutrition (general, pellagra)
      2. Alcoholism
      3. Malabsorption (celiac disease, tropical sprue)
      4. Pernicious anemia
   2. Carcinoma
   3. Diabetes mellitus
   4. Drugs and toxins
   5. MS
   6. Uremia (chronic renal disease)
   7. Traumatic injury
   8. Leprosy or neurosyphilis; hereditary disorders
      1. Hereditary sensory radicular neuropathy
      2. Angiokeratoma corporis diffusum (Fabry’s)
      3. Amyloid neuropathy
6. Ulcerations or abscesses complicated by diabetes or vascular insufficiency
7. Medical conditions that prevent self-care of these services

Non-Covered Services

The following list includes, but is not limited to, podiatry services which are not covered by PrimeWest Health:

1. Surgical assistant services (differing from assisting surgeons)
2. Local anesthetics that are billed as a separate procedure
3. Operating room facility charges
4. Routine foot care:
   1. Foot hygiene (cleaning and soaking the feet to maintain a clean condition)
   2. Cutting or removal of corns and calluses (except as noted above)
   3. Trimming, cutting, clipping, or debriding of nails (except as noted above)
   4. Use of skin creams to maintain skin tone
   5. Any other service performed in the absence of localized illness, injury, or symptoms involving the foot
5. Services not covered by Medicare or services denied by Medicare:
   1. Subluxation of the foot
   2. Treatment of flat feet
   3. Routine foot care
6. Stock orthopedic shoes, except when attached to a leg brace
7. Routine supplies provided in the office. Refer to List of Routine Supplies section.

Coverage Limitations

The following coverage limitations apply to podiatry services:

1. When a physician or podiatrist provides services to LTCF residents:
   1. The referral must result from the resident, an RN, or licensed practical nurse (LPN) employed by the facility, the resident’s family, guardian, or attending physician;
   2. The LTCF must document the referral in the medical record; and
   3. LTCF is responsible for routine foot care.
2. Coverage for the debridement and reduction of nails, corns, and calluses are limited to once every 60 days
3. For established patients, a podiatry visit charge must not be billed on the same day as the date for services described for debridement or reduction of nails, corns, and calluses
4. Provider may bill the avulsion and excision codes only once per nail

Billing

1. Podiatry services are billed in the 837P format. Refer to Billing Requirements.
2. National foot care modifiers are required on all routine foot care services, regardless of specialty.

Anesthesia Services

Anesthesia services are provided to patients undergoing surgical or non-surgical procedures in an outpatient or inpatient setting that requires the administration of an anesthetic. The reporting of anesthesia services is appropriate by or under the responsible supervision of a physician. These services may include, but are not limited to, general, regional, supplementation of local anesthesia, or other support services in order to provide the member the anesthesia care deemed appropriate.

These services include pre-operative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood, and the usual monitoring services (electrocardiogram [ECG], temperature, blood pressure, oximetry, capnography, and mass spectrometry).

Pre-Anesthetic Evaluations and Postoperative Visits

PrimeWest Health uses the Centers for Medicare & Medicaid Services (CMS) list of base values, which were adopted from the relative base values established by the American Society of Anesthesiologists (ASA). The base value for anesthesia services includes usual pre-operative and postoperative visits. No separate payment is allowed for the pre-anesthetic evaluation regardless of when it occurs unless the member is not induced with anesthesia because of a cancellation of the surgery.

If an anesthetic is not administered due to a cancellation of the surgery, the anesthesiologist or the independent CRNA may bill an Evaluation and Management (E/M) Current Procedural Terminology (CPT) code that demonstrates the level of service performed.

Criteria for Medical Direction

Anesthesiologists can be reimbursed for the personal medical direction (as distinguished from supervision) that they furnish to CRNAs.

Medical direction services personally performed by an anesthesiologist will be reimbursed only if the anesthesiologist does all of the following:

1. Performs a pre-anesthetic examination and evaluation
2. Prescribes the anesthesia plan
3. Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence (if applicable)
4. Ensures that any procedures in the anesthesia plan that he/she does not perform are performed by a qualified individual
5. Monitors the course of anesthesia administration at frequent intervals
6. Remains physically present in the surgical suite and available for immediate diagnosis and treatment of emergencies
7. Provides indicated postanesthesia care

If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation and another may fulfill the other criteria. Similarly, one physician member of the group may provide postanesthesia care, while another member of the group provides the other component parts of anesthesia services. However, the medical record must indicate that physicians provided the services and identify the physicians who rendered them.

PrimeWest Health will reimburse anesthesiologists for supervision of residents per Medicare’s formula and restrictions. The teaching physician must be present during induction, emergence, and during all critical portions of the procedure, and immediately available to provide services during the entire procedure. The documentation in the medical records must indicate the teaching anesthesiologist’s presence or participation in the administration of the anesthesia. The teaching physician’s presence is not required during the pre-operative or postoperative visits with the member. PrimeWest Health follows Medicare guidelines for reimbursement to anesthesiologists for the supervision of residents. PrimeWest Health does not reimburse for anesthesia assistants or interns.

Concurrent Medical Direction of CRNAs

In all cases in which the anesthesiologist provides medical direction, he/she must be physically present in the operating suite.

If the anesthesiologist supervises anesthetists during five or more concurrent procedures, payment can be made only for patient services personally performed by the anesthesiologist, not to exceed three base units plus 15 minutes for induction.

The billing or scheduling records that describe the anesthesia services provided must indicate the number of CRNA procedures concurrently medically directed by the anesthesiologist.

Calculation of Concurrent Medically Directed Anesthesia Procedures

Concurrency is defined with regard to the maximum number of procedures that the anesthesiologist is medically directing within the context of a single procedure and whether or not these other procedures overlap each other. The following example illustrates the concept of concurrency:

Criteria for Supervision

When the anesthesiologist does not fulfill the above criteria or is involved in supervising more than four procedures concurrently, his/her supervisory services are considered services to the hospital and are reimbursable only to the hospital. However, payment will be considered for pre-anesthesia services up to and including induction, when personally performed by the anesthesiologist.

Supervision of Anesthesia Service by Surgeon

PrimeWest Health will not reimburse a surgeon for supervision of anesthesia services provided by a CRNA, anesthesia assistant, intern, or resident.

Payment for Qualifying Circumstances

PrimeWest Health reimburses anesthesia “for a patient of extreme age” only if the patient is less than one year or over 70 years. Bill the anesthesia for a patient of extreme age code on a separate line and bill for one unit. Do not use anesthesia modifiers.

Monitored Anesthesia Care (MAC)

MAC is a specific anesthesia service in which an anesthesiologist or CRNA has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.

MAC includes all aspects of anesthesia care: a pre-procedure visit, intraprocedure care, and post-procedure anesthesia management.

During MAC, the anesthesiologist or CRNA must be continuously physically present and provide a number of specific services, including, but not limited to the following:

1. Monitoring of vital signs, maintenance of the patient’s airway, and continual evaluation of vital functions
2. Diagnosis and treatment of clinical problems that occur during the procedure
3. Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other medications as necessary to ensure patient safety and comfort
4. Provision of other medical services as needed to accomplish the safe completion of the procedure

Anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely. MAC refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. If, for an extended period, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic.

MAC by a CRNA

MAC is a covered service if the CRNA performs the above-described services. The time the CRNA is physically present with the patient is covered. Use the appropriate anesthesia or surgical procedure code to bill this service and indicate the exact number of minutes in direct patient contact. Modify the procedure code indicating the service was done under medical direction or performed independently. Indicate QS as the secondary modifier.

MAC by an Anesthesiologist

MAC is a covered service if the anesthesiologist performs the above-described services. The time the anesthesiologist is physically present with the member is covered.

An anesthesiologist may not bill for monitoring time not spent in direct contact with the member. Use the appropriate anesthesia or surgical procedure code to bill this service and indicate the exact number of minutes in direct contact. If the anesthesiologist is billing for medical direction, the anesthesiologist must meet the standards for medical direction. Modify the procedure code indicating medical direction or personally performed. Indicate QS as the secondary modifier.

Conscious Sedation

The intent of conscious sedation is for the patient to remain conscious and able to communicate during the entire procedure. The patient retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and/or verbal command. Conscious sedation includes performance and documentation of pre- and post-sedation evaluations of the patient, administration of the sedation and/or analgesic agents, and monitoring of cardiorespiratory functions (pulse oximetry, cardio respiratory monitor, and blood pressure).

Conscious sedation may be administered by physicians who have received training in moderate sedation. Follow current CPT guidelines for the use of conscious sedation codes. Conscious sedation codes cannot be billed when anesthesia services are provided at the same time.

Deep Sedation

Deep sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.

Deep sedation may be administered by emergency medicine physicians whose advance practice training has prepared them for airway management, advanced life support, and rescue from any level of sedation.

Use the appropriate anesthesia or surgical procedure code to bill deep sedation and indicate the exact number of minutes in direct patient contact. When deep sedation is performed by emergency medicine physicians, add modifier AA to the procedure code.

Patient-Controlled Analgesia (During Hospitalization)

PrimeWest Health covers patient-controlled analgesia for pain with the continuous infusion of pain medication facilitated by an infusion pump in a hospital setting. PrimeWest Health will separately reimburse the placement of an intrathecal or epidural catheter. Bill the correct unmodified CPT surgical procedure for the catheter placement. Do not bill the placement of the catheters with time units or with anesthesia modifiers.

PrimeWest Health covers the daily pain management service that is medically necessary. The service must be conducted face-to-face. Use the appropriate CPT code to bill this service. This service is not billed in units of time and is limited to one service per day.

Epidural Analgesia for Vaginal or Cesarean Delivery

The CPT code that describes the service of continuous epidural analgesia for labor and vaginal or Cesarean delivery includes the placement of the epidural catheter. Do not bill the placement of the epidural catheter separately. Indicate the number of minutes in the units field or the unshaded area of box 24G that the anesthesiologist or CRNA is physically present with the recipient.

Anesthesia for Ocular Procedures and Pacemakers

Anesthesia policy for ocular and pacemaker surgery follows Medicare guidelines.

Special Services Provided by Anesthesiologists or Independent CRNAs

PrimeWest Health covers specialized services performed by an anesthesiologist or independent CRNA, such as insertion of Swan-Ganz catheters, placement of central venous lines, arterial lines, etc. Bill these services with the appropriate unmodified CPT codes that describe the services. Bill the services as surgical procedures and no time units.

Billing for Anesthesia Services

Claims Documentation Requirements

Submit claims for anesthesia services in the 837P format. Use specific CPT ASA anesthesia codes or surgical codes with the appropriate anesthesia modifier. For authorized surgical services, PrimeWest Health prefers that anesthesia services are billed using surgical procedure codes with the appropriate anesthesia modifier.

Anesthesiologists and CRNAs must comply with PrimeWest Health requirements for billing sterilization procedures. Refer to Obstetrics and Gynecology (OB/GYN) Services for additional information.

Exact Minutes

Submit the exact number of minutes from the preparation of the patient for induction to the time when the anesthesiologist or the CRNA was no longer in personal attendance or continues to be required. Enter only the number of minutes in the units field. PrimeWest Health will calculate the base units for each procedure.

Modifiers and Rate Formulas

PrimeWest Health follows Medicare coverage standards for direction and supervision of CRNAs, Student Registered Nurse Anesthetists (SRNAs), and anesthesia residents. Time units equal the number of minutes from preparation of the patient to the time when the anesthetist is no longer in personal attendance or continues to be required. The number of time units divided by 15 is truncated at one decimal place. Example: 62 / 15 = 4.1.

2025 Anesthesia Rates

2024 Anesthesia Rates

Modifiers

CRNA Billing by Inpatient Hospitals

Inpatient CRNA services must not be billed separately if a hospital has chosen to have those services paid as part of the inpatient rates.

Enrolled CRNA – Employee Billing

CRNA services provided in an outpatient hospital setting by any of the following must be billed in the 837P format:

1. CRNA who is independent or employed by a physician
2. CRNA employed by a hospital that chose to remove CRNA costs from its inpatient rate
3. An entity not enrolled as a hospital that is billing CRNA services
4. A Critical Access Hospital (CAH) that does not qualify for the CRNA billing exemption under Medicare Part B

CRNA – Independent Billing

CRNA services provided by an independent CRNA must be billed of a hospital that has chosen to remove CRNA costs from its inpatient rate.

Family Planning

1. PrimeWest Health covers family planning services and supplies for men and women of childbearing age, including minors.
2. Members must be free of coercion and free to choose the method of family planning they want to use.
3. The provider cannot require that an unmarried minor’s parent or guardian consent to family planning services for the minor.
4. Family planning services have no copays.

Confidentiality

Family planning services do not appear on any explanations of benefits (EOBs) sent to the member or member’s family.

Providers

1. Physicians
2. CNMs
3. CNPs
4. Physician Assistants (PAs)
5. Clinical Nurse Specialists (CNSs)
6. Clinics, outpatient hospital departments, pharmacies, and family planning agencies may provide some or all of the available family planning services and family planning supplies (refer to applicable sections for information and requirements relevant to the various providers).

Dispensing by Protocol – Family Planning Registered Nurse (RN)

An RN in a family planning agency may dispense oral contraceptives prescribed by a licensed practitioner, according to a dispensing protocol established by the agency’s medical director or under the direction of a physician. RNs may not dispense oral contraception to a member who is less than 12 years of age. Follow state requirements for dispensing prescription drugs.

Refer to the applicable sections for information and requirements relevant to the various providers.

Free Choice of Provider

All PrimeWest Health members have free choice of family planning providers and may obtain the following services from any qualified provider, including those outside of the PrimeWest Health provider network:

1. Family planning, including family planning supplies and sterilization (does not include abortion)
2. Testing and treatment of an STD/STI
3. Testing for Acquired Immune Deficiency Syndrome (AIDS) and other HIV-related conditions; this does not include treatment for HIV/AIDS. PrimeWest Health members must seek treatment for HIV/AIDS through the PrimeWest Health network.
4. Diagnosis of medical conditions that result in infertility; this does not include treatment for infertility. PrimeWest Health members must seek infertility treatment through the PrimeWest Health network.

Eligible Members

All PrimeWest Health members, of childbearing age, including minors, are eligible to receive family planning services.

Covered Services

The following family planning services are covered (although all providers listed above may not directly provide all of these services):

1. Contraceptive devices (e.g., diaphragm, intra-uterine device [IUD])
2. Family planning supplies (e.g., condoms, thermometers)
3. Contraceptive injections
4. Prescriptions for the purpose of family planning
5. Emergency contraception
6. Consultation, examination, and medical treatment
7. Genetic counseling
8. Family planning counseling
9. Laboratory examination and tests, including screening for cervical cancer by Pap smear and pregnancy testing as clinically indicated
10. Infertility services, limited to diagnosis and treatment of medical problems causing infertility (e.g., pituitary or ovarian tumor, testicular mass; refer to Non-Covered Services section below)
11. Voluntary sterilization (refer to Sterilization section)
12. Testing for STIs
13. STI prevention techniques (e.g., vaccinations and condoms)
14. Treatment of non-HIV-related STIs
15. HIV blood screening and counseling (performed before and after HIV blood screening test)

Lab Services

Refer to Laboratory/Pathology, Radiology, and Diagnostic Services Covered Services when ordering or referring lab tests.

Certified MFPP providers may perform or order lab tests that are performed during the PE period under the conditions that the MFPP-certified provider found the recipient presumptively eligible.

Secondary MFPP Services

Applicable secondary MFPP procedure codes are are covered only when they meet one of the following:

1. Provided on the same date of service as the primary family planning services and billed with a primary diagnosis code in the applicable range
2. Provided as follow-up to a previous primary family planning visit within the preceding 180 days, if the member is still enrolled as a PrimeWest Health member and reported with the most appropriate ICD primary diagnosis code

The member must have full knowledge of and consent freely to all family planning services.

Non-Covered Services

1. Reversal of voluntary sterilization
2. Fertility drugs and all associated services
3. Artificial insemination, including in vitro fertilization
4. Surrogate pregnancy services

Billing

For more information on billing, please see electronic data interchange (EDI) requirements in Billing Requirements.

1. Bill in the 837P claim format electronically.
2. Pharmacies: Bill MedImpact Healthcare Systems, Inc. via point of sale for all medications. Supplies and devices can be billed directly to PrimeWest Health on the 837P claim format.
3. If you provide oral contraceptive products and emergency contraceptives on the same date of service, list them on separate lines. 
4. For genetic counseling, refer to the special billing instructions in Physician and Professional Services.

Sterilization

Overview

Sterilization is any medical procedure, treatment, or operation for the purpose of rendering a person permanently incapable of reproducing.

Eligible Providers

The following providers must be enrolled with Minnesota Health Care Programs (MHCP) to provide sterilization services: 

• Ambulatory surgical centers
• Certified Registered Nurse Anesthetists (CRNAs)
• Federally qualified health centers
• Hospitals
• Indian Health Services facility providers
• Nurse midwives
• Nurse practitioners
• Physician assistants
• Physicians
• Rural health clinics

Eligible Members

The following criteria must be met in order for sterilization services to be covered by PrimeWest Health. Emergency Medical Assistance (major program code EH) does not cover sterilization services.

• The individual is age 21 or over at the time the Consent for Sterilization form is signed
• The individual is mentally competent
• The individual is not institutionalized
• The individual has voluntarily signed the Consent for Sterilization form (a consent form signed by a guardian, conservator, or anyone other than the individual to be sterilized will not be accepted)
  • Dates: Dates corresponding to signatures must be filled in by the person whose signature is on the preceding line (patient, interpreter, person obtaining consent, or physician). The Consent for Sterilization form dates must not be typed onto the form or filled in by someone other than the signatory. Dates can be changed only to correct a clerical error. If, for example, a person writes “1/8/2019” instead of “1/8/ 2020,” the error should be struck through, but not obliterated, and the correct date entered. The reason for the change should be evident.
  • The member to be sterilized must sign and date the sterilization consent form. At least 30 days, but not more than 180 days, must pass between the date the member signed the sterilization consent form and the date of surgery.
  • The interpreter, if one was provided, must sign and date the sterilization consent form after the member signs, but before the day of surgery
  • The person obtaining the consent must sign and date the consent form after the member signs, but before the day of surgery. The person obtaining the consent certifies by signing the sterilization consent form that they explained the requirements for informed consent orally and, to the best of their knowledge and belief, the member to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.
  • The physician who performs the sterilization procedure must sign and date the consent form shortly before (no more than 15 days) the day of surgery, or at any time after the surgery. The physician certifies, by signing the sterilization consent form, that they advised the member to be sterilized that no Federal benefits will be withdrawn if the member chooses not to be sterilized, explained the requirements for informed consent, and, to the best of their knowledge and belief, the member to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

Retroactive Eligibility

Consent for Sterilization form requirements cannot be met retroactively. When a member without financial resources or insurance coverage requests sterilization and indicates that they are considering applying for or has applied for Medical Assistance (Medicaid), the provider may obtain informed consent, complete a Consent for Sterilization form, and allow for the 30-day waiting period. Informed consent, a completed Consent for Sterilization form, and 30-day waiting period requirements must still be met. 

If a member becomes retroactively eligible for MHCP and paid for the sterilization procedure within the retroactive period, the provider must reimburse the member the full amount paid and may then bill MHCP if there is a valid sterilization consent form and the 30-day waiting period was observed.

Covered Services

All sterilization procedures must follow MHCP sterilization requirements. The following sterilization services are covered:

• Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy, not otherwise specified (NOS)
• Anesthesia, tubal ligation/transection
• Hysteroscopy, surgical with bilateral fallopian tube cannulation to induce occlusion 
• Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
• Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, Falope ring)
• Ligation or transection of fallopian tube(s), abdominal or vaginal approach
• Occlusion of fallopian tube(s) by device (band, clip, Falope ring), vaginal or suprapubic approach
• Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen exam

Non-Covered Services

The following services are not covered:

• Reversal of voluntary sterilization
• Sterilization of a mentally incompetent individual
• Sterilization of a member institutionalized voluntarily, civilly committed or court-ordered, in an:
  • Intermediate Care Facility for People with Developmental Disabilities or Related Conditions (ICF/DD-RC)
  • Regional Treatment Centers that are not Institutions for Mental Disease (RTC, not IMD)
  • Regional Treatment Centers that are Institutions for Mental Disease (RTC-IMD)
  • IMDs
  • Correctional facilities (county or non-county)
  • Chemical dependency (CD) rehabilitation programs
  • Residential facilities for mentally ill persons
• Sterilization of anyone who consented to sterilization and was under age 21 at the time of consent 
• PrimeWest Health does not cover sterilization procedures without the informed consent of the individual being sterilized. Under no circumstances will PrimeWest Health pay for a sterilization in which a person has given consent for another person. This includes court-ordered sterilization of a mentally incompetent or institutionalized individual.
• Sterilizations consented to by members:
  • In labor or childbirth
  • Seeking to obtain or obtaining an abortion
  • Under the influence of alcohol or other substances that affect the member’s state of awareness
  • In a situation in which the provider believes that the member is unable to give informed consent

Service Requirements

Providers must obtain consent and be in possession of a completed and signed Consent for Sterilization form.

Required Counseling

The person obtaining the consent for the sterilization must answer the member’s questions regarding the procedure, provide a copy of the Consent for Sterilization form, and explain the requirements for informed consent that are listed on the form. In addition, shortly before the sterilization, the physician who will perform the procedure must explain the requirements for informed consent that are listed on the Consent for Sterilization form.

Interpreter Services

The provider must provide the following: 

• A language interpreter to ensure that the information about the sterilization is accurately and clearly communicated to members who do not understand English. 
• A sign language interpreter to ensure that information is accurately and clearly communicated to members who are hearing impaired.

Obtaining Consent

The Code of Federal Regulations (CFR) (Title 42 CFR 441, subp. F) outlines requirements, including use of the Consent for Sterilization form and for obtaining informed consent, which must be met for PrimeWest Health to reimburse providers for performing sterilization procedures. The requirements apply to all PrimeWest Health members. Under no circumstances will these requirements be waived.

It is the physician’s responsibility to obtain informed consent. If the physician does not believe the member can give informed consent, the physician should not perform the sterilization or may request additional information to determine whether the member is capable of giving informed consent (such as a psychiatric evaluation).

Transfer of Consent

If a member moves or changes providers, the sterilization consent form may be transferred to the new provider. However, the physician who performs the surgery must complete the physician section and sign within the appropriate time limits.

Consent for Sterilization Form

The Consent for Sterilization form must be completed for PrimeWest Health to reimburse providers for performing sterilization procedures. This requirement applies to all PrimeWest Health members with Medical Assistance and MinnesotaCare. Emergency Medical Assistance (EMA) (major program code EH) does not cover sterilization services.

Different guidelines apply for hysterectomies. Refer to Hysterectomy in the PrimeWest Health Provider Manual. 

Resources

• Consent for Sterilization form 
• Permanent Contraception (Centers for Disease Control and Prevention)

If a facility or provider needs to reformat the Consent for Sterilization form, a disclaimer must be added in the top left corner of the header that states the following: 

    “__(insert facility or provider name) ______certifies the text contained in this Sterilization Consent form complies with the text in 42 CFR Part 441, Subpart F Appendix.”

The facility or provider must complete a Consent for Sterilization form for each PrimeWest Health member who requests a sterilization procedure. The Consent for Sterilization form creates an opportunity for providers to obtain informed consent by giving the member the following:

• An opportunity to ask questions about the sterilization process
• An oral explanation about the procedure and any procedural risks according to sterilization consent form requirements
• A copy of the Consent for Sterilization form
• Advice that the decision to be sterilized will not affect future care or benefits and that the sterilization will not be performed for at least 30 days, except in the case of premature delivery or emergency abdominal surgery

Exceptions to Timelines

The following exceptions apply to the Consent for Sterilization form timelines: 

• Emergency abdominal surgery – when the member to be sterilized requires emergency abdominal surgery, the sterilization may be covered at the time of the emergency abdominal surgery if at least 72 hours have passed since the member signed the consent form.
  • Note: An emergency Cesarean section is not considered emergency abdominal surgery.
• Premature delivery – when the member to be sterilized goes into premature delivery, the sterilization may be covered if at least 72 hours from the “From date” of admission have passed since the member signed the consent form and the member signed it at least 30 days before the expected date of delivery.

The instructions for use of alternative final paragraph section (under the Physician’s Statement heading of the Consent for Sterilization form) requires a choice between paragraph one or paragraph two. If paragraph two is selected, provide information about the premature delivery or emergency abdominal surgery. 

Free Choice of Provider

Sterilization is a family planning service. All PrimeWest Health members have free choice of family planning providers and may obtain family planning services from any qualified provider, including those outside of the PrimeWest Health provider network.

Billing

• Bill electronically
• Fax a copy of the Consent for Sterilization form for all sterilization claims, including physician, anesthesiologist, CRNA and hospital or surgical center following the instructions on the DHS Electronic claim attachments web page 
• Use the appropriate diagnosis code 

For Minnesota Family Planning Program (MFPP) members, refer to the specific codes on the Minnesota Family Planning Program (MFPP) Healthcare Common Procedure Coding System (HCPCS) Codes web page. 

Hysterectomy

A hysterectomy is a medically necessary procedure or operation for the purpose of removing the uterus. PrimeWest Health does not cover hysterectomy for sterilization purposes.

42 CFR 441, subp. F, outlines requirements, including member acknowledgment of information, that must be followed for PrimeWest Health to reimburse providers for performing hysterectomy procedures. See the sample Hysterectomy Acknowledgment Statement (HAS) at the end of this section.

Authorization Standards for Hysterectomy

PrimeWest Health is contractually required by DHS to review medical necessity and utilization of non-emergent hysterectomy. Claims for non-emergency hysterectomies are subject to retroactive review by PrimeWest Health for medical necessity. Prior authorization is not currently required.

A HAS must be completed and retained in the member’s file.

Conditions supporting medical necessity for hysterectomy may include, but are not limited to, the following:

1. Malignant disease of the cervix, uterus, ovaries, or fallopian tubes
2. Symptomatic uterine fibroids (leiomyomas) that are either:
   1. Causing bladder pressure, pain, fullness, functional disturbance;
   2. Bleeding unresponsive to conservative therapy; or
   3. Showing rapid and progressive enlargement.
3. Recurrent or persistent uterine bleeding or discharge with failure to respond to conservative management
4. Confirmed diagnosis of endometriosis with documented failure of non-surgical management (e.g., use of hormonal therapy and/or low-dose contraceptives)
5. Endometritis that is unresponsive to conservative management
6. Chronic pelvic inflammatory disease unresponsive to conservative management
7. Adenomatous endometrial hyperplasia with moderate or severe atypia recurring despite conservative management
8. Obstetrical catastrophes, such as uncontrollable postpartum bleeding, uterine rupture, uncontrolled uterine sepsis developing from septic abortion, placenta accretion, etc.
9. Septic abortion not responsive to conservative management
10. Removal of the uterus in non-gynecologic pelvic surgery where necessary to encompass disease originating elsewhere, as in uterine involvement in colon cancer or in abscesses secondary to diverticulitis
11. Symptomatic uterine prolapse or descent resulting in general pelvic relaxation
12. Other conditions determined to be medically necessary

Eligible Providers

1. Ambulatory surgical centers
2. Certified Registered Nurse Anesthetists (CRNAs)
3. Hospitals
4. Tribal and Federal Indian Health Facility Services
5. Nurse midwife
6. Nurse practitioner
7. Physician assistant
8. Physicians

Covered Services

All medically necessary hysterectomy procedures/operations for the purpose of removing the uterus are covered.

Non-Covered Services

A hysterectomy is not covered when:

1. Performed solely for the purpose of making a member sterile; or
2. More than one purpose exists for the procedure, and the hysterectomy would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

Written Acknowledgment

A written HAS is required in order for the procedure to be covered.

1. PrimeWest Health requires the provider to secure authorization to perform a hysterectomy by informing the individual (and her representative, if applicable) that the hysterectomy will make her permanently incapable of reproducing.
2. The individual and her representative, if any, must sign an HAS verifying that the member received this information, both orally and in written form. The HAS must be retained in the member’s file.
   
   A sample HAS is included at the end of this section. It is not mandatory for the provider to use this sample acknowledgment statement. Any document that the individual (or her representative) has signed that shows the provider informed the individual that she would be incapable of reproducing due to the hysterectomy is permissible.
   
   Do not use the Sterilization Consent Form. PrimeWest Health does not cover a hysterectomy as a means for sterilization.
3. The member or guardian may sign the HAS before or after the hysterectomy. However, if the statement is signed after the hysterectomy, it must indicate that before the surgery took place, the member was informed that the hysterectomy would make her sterile.
4. Guardians must sign the HAS for mentally incompetent members.
5. A member residing in an institution, such as an RTC, may sign the HAS for herself unless she has been found incompetent by a court or unless the head of the institution determines that the member is incompetent and requires a representative.
6. The HAS must be faxed as an attachment following the electronic claim attachment instructions found in Billing Requirements, on any claim(s) submitted by the physician, anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), and hospital.
   
   Sample Hysterectomy Acknowledgment Statement
   
   My doctor informed me, both orally and with written materials, that the performance of a hysterectomy would make me sterile (not able to have children).
   
   Signed ________________________________________________ Date ________________________
   
   If the member signs the acknowledgment after the hysterectomy, the acknowledgment must show that the member was informed of the consequences of the hysterectomy before the procedure was performed.

Exceptions to Hysterectomy Acknowledgment Statement (HAS)

The written HAS requirement is waived in the following situations:

1. Life-Threatening Emergency: When a member needs a hysterectomy because of a life-threatening emergency in which a physician determines that prior acknowledgment is not possible. The physician must provide a written certification (including physician signature and date) that prior acknowledgment was not possible and describe the nature of the emergency.
2. Member Already Sterile: A hysterectomy performed on a member who was sterile before the surgery is not subject to the written acknowledgment requirement.
   
   In both situations, the physician who performed the hysterectomy must provide a written certification (including physician signature and date) that prior acknowledgment was not possible and describe the nature of the emergency, or of the member’s sterility and the cause of the sterility.

The physician’s certification must be faxed as an attachment following the electronic claim attachment instructions found in Billing Requirements.

The patient chart/medical record must indicate sterility prior to surgery. Refer to sample statement below.

Sample Statement – Recipient Already Sterile

(Recipient’s name) had a tubal ligation procedure on (date) making her sterile prior to the hysterectomy performed on (date).

Signature of physician __________________________________ Date ________________________

Billing

Use an 837P or 837I claim form.

Obstetrics and Gynecology (OB/GYN) Services

PrimeWest Health covers obstetric services, including prenatal care, enhanced prenatal care for high-risk pregnancies, delivery, postpartum and newborn care, and HIV counseling for pregnant Medical Assistance and MinnesotaCare members.

Eligible Providers

• Certified nurse midwife (CNM)
• Certified Nurse Practitioner (CNP)
• Clinical Nurse Specialist (CNS)
• Certified Professional Midwife (CPM)
• Clinics
• Doctor of osteopathy (DO)
• Outpatient hospital
• Physician (MD)
• Physician assistant (PA)
• Physician extenders

Non-Covered Services

Services related to surrogate pregnancies are not covered by PrimeWest Health.

Certified Nurse Midwife (CNM) Services

Enrollment

A CNM is a person licensed as a registered nurse by the Board of Nursing and certified by a national nurse certification organization acceptable to the Board of Nursing to practice as a nurse midwife.

Scope of Service

Payments for services provided by a CNM are limited to those within the CNM’s scope of practice, provided directly to the patient, and in accordance with Minnesota law.

• A CNM may enroll as an independent PrimeWest Health provider.
• CNMs must practice within a system that provides for consultation, collaborative management, and referral as indicated by the health status of members.
• CNMs may prescribe, administer, and dispense drugs and therapeutic devices within the scope of practice of a CNM as defined in Minnesota law.

Billing

• Refer to billing sections for detailed instructions on billing maternity and delivery care, enhanced services, and standby attendance for newborn care.
• To receive payment, the CNM’s individual National Provider Identifier (NPI) must be entered as the rendering provider on the 837P or 837I claim format. Do not use a modifier when billing CNM services.
• If a CNM provides services as part of a clinic or physician practice (group clinic or physician office), the 837P claim format should include the clinic or physician group NPI in the “Billing Provider” field. The CNM individual NPI must be entered in the rendering provider field on the electronic claim format.
• CNM services as part of a CNM practice must be billed with the CNM’s individual NPI in MN-ITS as the filling/paid-to provider.

Certified Neonatal Nurse Practitioner (CNNP) Services

Enrollment

Neonatal nurse practitioners (NNPs) are eligible to enroll in PrimeWest Health and bill for services provided when the following criteria are met:

1. The NNP is certified as an NNP by the Minnesota Board of Nursing and according to Minnesota law
2. The NNP is in independent practice

Covered Services

Services performed by a CNNP are covered under the following circumstances:

1. The service provided is a physician service
2. The service is within the scope of practice of the CNNP
3. The service is a covered service
4. The service is medically necessary
5. The service, if provided on an inpatient basis, is not included as part of the cost for inpatient services included in the hospital’s operating payment rate. If services have been billed historically by a hospital as inpatient services, the costs for these services are included in the calculation of the hospital’s payment. Therefore, these services cannot be billed separately by another provider.
6. The service is within the scope of practice of the CNNP as described in MN Stat. secs. 148.171 – 148.285

Doula Services

Overview

Minnesota Health Care Programs (MHCP) covers doula services. These services include emotional and physical support for pregnant people.

Recommendation for Doula Services

Medical Assistance (Medicaid) and MinnesotaCare Medical Director Nathan T. Chomilo, MD, FAAP, FACP, issued a statewide standing recommendation for doula services. Now, an eligible MHCP member may seek out and receive care from an MHCP-enrolled doula services provider without getting their own individual referral or written recommendation from a physician. Refer to Recommendation for Doula Services for Pregnant and Postpartum Minnesota Health Care Programs Members for the full recommendation. 

Eligible Providers

Doulas who are registered with the Minnesota Department of Health (MDH) may enroll as doula providers for MHCP. Review Doula Enrollment and Criteria and Forms for details. MHCP-enrolled doula providers are allowed to provide or bill for doula services for an MHCP member per the Recommendation for Doula Services for Pregnant and Postpartum Minnesota Health Care Programs Members.

Eligible members

All pregnant Special Needs BasicCare (SNBC), MinnesotaCare, and Families and Children PrimeWest Health members are eligible to receive doula services from enrolled providers. 

Covered Services

Covered services include informational, emotional, and physical support for pregnancy, labor and delivery, and postpartum birthing people. Spiritually and culturally responsive care is also covered. 

PrimeWest Health covers up to 18 sessions without prior authorization. These 18 sessions can be completed at any time during the prenatal, labor and delivery, and postpartum periods. Refer to the Doula Services Authorization Requirements section in the DHS Provider Manual for information on providing additional sessions if the member requires more than 18.

MHCP covers doulas who attend labor and delivery in settings where a licensed birthing professional is attending the birth. These settings include hospitals, birth centers, and within the home (home births). 

MHCP covers attendance of a doula during a labor that results in an emergency Cesarean delivery. 

Non-Covered Services

Travel time and mileage are not covered services.

Documentation Requirements

Document each visit with a member in either written or electronic format, including the following information from the visit: 

• The member’s name
• The date of the visit
• Length of time spent with the member
• What was done, discussed, and recommended in the visit 
• Any other important information from the visit. For example, if the member reports pain or high blood pressure, providers should note the concerns and recommendations they made on how to follow-up or to see a provider. 
• The signature of the doula providing the service

Other standards apply (including that the documentation must be legible). Review the Health Service Records section of Provider Requirements in the MCHP Provider Manual for more information. 

Authorization Requirements

To provide additional sessions (more than 18), the doula must request prior authorization following the guidelines in the Service Authorization section. Include documentation supporting the medical necessity of the additional sessions with the request.

Telehealth

A telehealth labor and delivery doula visit can be billed if the member’s needs were met by the doula during the labor and delivery process; and the doula was available to the member with no other commitments throughout the entirety of the labor and delivery process by telephone or video conference.

If the doula was unavailable during the entirety of the labor and delivery process but was able to provide key support during some of the labor and delivery, they may bill for a non-labor and delivery visit for their time spent with the member.

Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) to DHS to bill for telehealth services. Review the Telehealth Services section of the MHCP Provider Manual for more information.

Billing

Refer to Billing Requirements for an overview of PrimeWest Health billing policies and procedures, which includes the following:

• Bill using the 837P
• Enter the rendering doula’s provider identification number in the Rendering Provider box in MN–ITS 
• Enter the provider identification number for the billing provider (this can be either the doula’s provider identification number if they are billing individually, or the billing provider’s provider identification number if they are the pay-to provider for the doula) in the "Pay-To-Provider" box in MN–ITS
• Bill all non-labor and non-delivery sessions with T1033 (no modifier)
• Bill all labor and delivery sessions with T1033 and the U4 modifier
• If the labor progresses over multiple days, bill for the date the doula was present providing services. Or, if the doula was present throughout labor and delivery, bill the doula services for the date of the birth. 
• If the labor results in an emergency Cesarean delivery, the doula may still bill the labor and delivery session with T1033 and the U4 modifier. 

Free-Standing Birth Center Services

PrimeWest Health covers low-risk pregnancy and low-risk delivery services provided in a licensed free-standing birth center if a licensed health professional provides the service. Free-standing birth centers are licensed health care facilities in which licensed health care professionals perform low-risk deliveries following a low-risk pregnancy. A low-risk pregnancy is a normal, uncomplicated pregnancy. A free-standing birth center is not a hospital or licensed as part of a hospital. All free-standing birth centers must be accredited by the Commission for the Accreditation of Birth Centers (CABC). The Minnesota Department of Health (MDH) issues licenses for free-standing birth centers.

PrimeWest Health requires notification from hospitals and free-standing birth centers for all OB deliveries.

The notification must include the following:

• Mother’s name, DOB, and Personal Member Identifier (PMI) number
• Infant’s DOB, gender, and birth weight

Failure to notify PrimeWest Health with the above information following an OB delivery may result in denial or delayed claims payment.

Eligible Providers

Refer to Provider Requirements for detailed provider policies. PrimeWest Health reimburses free-standing birth center services performed by the following licensed providers:

• Certified Nurse Midwives (CNM) (must be licensed by the Minnesota Board of Nurses)
• Certified traditional midwives (CPMs) (must be licensed by the Minnesota Board of Medical Practice)
• Physicians

A licensed, free-standing birth center may only render care or services permitted within the scope of the issued license or accreditation.

Eligible Members

All Medical Assistance and MinnesotaCare members are eligible to receive free-standing birth center services.

Covered Services

Covered professional services include the following (all care must be documented):

• Prenatal visits
• Routine lab services
• Ultrasound
• Low-risk labor and delivery
• Postpartum visits
• Newborn care services
• Labor care prior to a hospital transfer
• All professional services associated with pregnancy, postpartum care, and newborn care

Birth Weight Requirement

PrimeWest Health requires that all claims for babies less than 29 days old include a birth weight. PrimeWest Health will deny claims that do not contain a valid birth weight. Include Value Code 54 (newborn birthweight in grams) on all claims for babies under 29 days at time of admission. This is regardless of whether the baby was born inside or outside the hospital, and of whether the newborn was transferred to or from the hospital. If an ICD-10 diagnosis code indicating birth weight is reported on the claim, the birth weight must correlate to the weight reported with Value Code 54.

Coverage Limitations

The following limitations apply to the services performed at a free-standing birth center:

• PrimeWest Health only covers surgical procedures normally provided during an uncomplicated birth, including episiotomy and repair
• PrimeWest Health only covers local anesthesia when administered within the scope of practice of a health care professional
• PrimeWest Health does not reimburse nursery charges separately
• PrimeWest Health covers ultrasounds for the Zika virus if a positive diagnosis is determined from a blood test

Non-Covered Services

• Services provided by an unlicensed traditional midwife
• Abortion services
• General or regional anesthesia

Billing Free-Standing Birth Center Services

• Refer to the Billing section for PrimeWest Health billing requirements
• Bill facility charges on the 837I, as follows:
  • For the birthing person: 
    • Type of bill is 0840 through 0848
    • Revenue code is 0724
    • Use code 59400 for deliveries in a free-standing birth center
      • This charge for the facility does not include the cost of a newborn screening card
      • Do not separately bill the newborn screening card fee (S3620) 
    • Use code 54005 for the transfer to a hospital
      • This charge for the facility does not include the newborn screening card cost.
      • If the newborn is born in a hospital setting but the screening was performed at home by the birth center following discharge from the hospital, bill the newborn screening card fee (S3620) 
    • Professional fees that are associated with the newborn screening can be billed on a professional claim
  • Newborn billing
    • Type of billing is 0840 – 0848
    • Revenue code is 0724
    • Use code 99463 when delivery is in the birth center 
• Bill CNM and CPM charges on the 837P
  • Use CPT code 59400 for antepartum (before birth) labor and vaginal delivery and postpartum care
  • If a member is transferred to a hospital before delivery, all professional services provided to the member in the free-standing birth center before the hospital transfer may be billed to PrimeWest Health
• Refer to Billing Requirements for detailed billing policy
• Refer to Laboratory/Pathology, Radiology, and Diagnostic Services for policy information and information regarding the newborn metabolic disorder screening

Pregnancy Health Education

Do not bill for classes that are provided free to non-PrimeWest Health members or Medicaid recipients.

Eligible Members

All MHCP members (Medical Assistance and MinnesotaCare) are eligible, except for Emergency Medical Assistance and Minnesota Family Planning Program members.

Use HCPCS code S9442 to bill for birthing classes. Bill one unit for each class encounter. A class that meets once a week for three weeks has three encounters. For weekend or Saturday classes, use the appropriate code and bill up to four units.

Public Health nursing clinics may bill for pregnancy health classes or other group education using S9446. Bill one unit per member for each class encounter. A class that meets once a week for three weeks has three encounters.

The following providers may provide and bill for prenatal education classes:

1. CNMs
2. CNSs
3. Enrolled physicians
4. Nurse practitioners (NPs)
5. PAs

In addition, clinics and outpatient hospitals whose prenatal education program is directed by one of the enrolled providers listed above may bill for RNs or health educators with at least a baccalaureate level degree in health education and/or certification for prenatal education from one of the following organizations:

1. International Childbirth Education Association (ICEA)
2. National Commission for Health Education Credentialing (NCHEC)
3. Lamaze
4. International Board of Lactation Consultant Examiners (IBLCE)

Lactation

PrimeWest Health covers lactation consultations and classes as a preventive care service during pregnancy and up to 12 months postpartum. 

Lactation consultations can be provided by certified lactation counselors, Indigenous lactation counselors, International Board-Certified Lactation Consultants, or other health educators with training in lactation. 

Lactation classes can be provided by a certified lactation educator, certified lactation counselors, Indigenous lactation counselors, International Board-Certified Lactation Consultants, or other health educators with training in lactation. 

Breast pumps and accessories are covered. One electric breast pump is covered per pregnancy. Refer to the Equipment and Supplies section for more details. 

Pasteurized donor human milk is covered for babies with a medical need when they don’t have another way to receive breast milk. Refer to "Nutritional Products and Related Supplies" in the Equipment and Supplies section for more details. 

Billing

Bill HCPCS code S9443 for lactation classes. Bill one unit for each class encounter. Example: A class that meets once a week for three weeks has three encounters. 

For lactation consultations, bill the appropriate code and place of service for each consultation. 

Prenatal Screening and Enhanced Services for High-Risk Pregnancies

Providers should screen all pregnant PrimeWest Health members using a standardized prenatal assessment tool such as the American College of Obstetricians and Gynecologists’ [ACOG] Obstetric Medical History or an assessment tool developed or customized in the provider’s office that is equivalent to one of the standardized tools. Keep a copy of the prenatal risk assessment in the member’s record. The assessment tool, whether standardized or customized, must maintain the information in a single document that can be easily separated from the medical record for review. This assessment is generally performed at the member’s first prenatal visit.

This assessment is generally performed at the member’s first prenatal visit.

A copy of the prenatal risk assessment may be mailed or faxed to PrimeWest Health at:

Attn: Maternal Child Care Coordinator
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Fax: 1-320-762-8750

Based on information gathered from the prenatal assessment and screening process, a provider may determine that a member is at high risk for an adverse birth outcome. Members determined to be high-risk are eligible for enhanced services. The primary care provider is responsible for ordering and referring a high-risk member to enhanced services. PrimeWest Health encourages providers to address these issues throughout the pregnancy. If necessary, up to three classes per day may be covered.

Enhanced Services for High-Risk Pregnancies

The following enhanced services are covered for high-risk pregnancies:

1. High-risk antepartum management
2. Care coordination
3. Prenatal Health Education I
4. Prenatal Health Education II: Lifestyle and Parenting Support
5. Prenatal nutrition education
6. Postpartum follow-up home visit

Refer to the Billing Enhanced Services section for limits and eligible providers.

High-Risk Antepartum Management (H1001)

When a pregnant person is identified as being high-risk, the primary care provider is eligible for PrimeWest Health payment for the additional time and expertise required, beyond routine prenatal care, to manage the member’s care based on their high-risk pregnancy. The primary care provider who is responsible for the care of the member during pregnancy determines what additional health services would benefit the member and provides medical care as determined by the member’s needs.

Care Coordination (H1002)

Care coordination is the development, implementation, and ongoing evaluation of the plan of care for a high-risk pregnant person. The care coordinator provides continuity, makes referrals, monitors the member’s progress, and advocates for the member to ensure access to services that support a healthy pregnancy and improve birth outcomes. Care coordination services include the following:

1. Documentation that the pregnant person is high-risk for an adverse birth outcome
2. Development of an individual plan of care that addresses the member’s specific needs and risks related to the pregnancy
3. Ongoing evaluation and, when appropriate, revision of the plan of care
4. Involvement of the pregnant person and their support network in the assessment and plan of care
5. Coordination of services and referrals to appropriate community resources and health care providers
6. Advocacy for the pregnant person in working with the various health care providers
7. Monitoring, on an ongoing basis, to determine whether or not the member is receiving enhanced prenatal services in a timely and economical manner, and that each service is of expected and adequate quality

Documentation Requirements for Care Coordination

1. A written, individualized plan of care that addresses the member’s specific needs related to the pregnancy, including any revisions of that plan
2. Evidence of all referrals made, and follow-up on those referrals
3. Evidence of the following activities: monitoring, coordinating, and managing nutrition and prenatal education services to ensure that they are provided in the most economical and efficient manner

Prenatal Health Education

Health education for the high-risk pregnant person is a core intervention that is preventive, resource-efficient, and consistent with the member’s individualized plan of care. Educational services are based on the pregnant person’s risks as identified on the prenatal screening tool, and their needs as determined by the primary care provider and care coordinator, in consultation with the pregnant person.

These members require innovative and individualized approaches to prenatal care to effectively meet their educational needs. Educational interventions target risk factors, medical conditions, and health behaviors that can be alleviated or improved through education. Educational services begin with the initial assessment visit and continue throughout the perinatal period. Services can be provided on a one-to-one basis, in small group settings, or in classes individualized to the person's own needs and interests. Prenatal health education promotes a healthy lifestyle that will support a healthy pregnancy and result in an improved perinatal outcome.

Prenatal Health Education I (H1003)

Prenatal Health Education I provides general information about pregnancy and prenatal care. It also covers high-risk medical conditions and lifestyle factors that can be improved through education. It can include the following topics:

1. Information about pregnancy and physical changes that occur during pregnancy, including the following:
   1. Normal changes due to pregnancy (specific to trimester)
   2. Anatomy and physiology related to pregnancy
   3. Fetal development
   4. Emotional and psychosocial concerns
   5. Description and importance of continued prenatal care
   6. Comfort measures
   7. Self-care during pregnancy
   8. Pregnancy danger/warning signs
   9. Specific medical conditions
   10. Diagnosis and significance of condition during pregnancy
   11. Treatments including medications, activity level, options, and rationale
   12. Appropriate referrals
2. Information to prepare the pregnant person for the birth process when they are near the end of the second trimester or early third trimester, including the following:
   1. Anatomy and physiology of labor and delivery
   2. Coping skills
   3. Medical management
   4. Hospital procedures
   5. Danger signs
   6. Communication with health providers
3. Information that helps the pregnant person identify and take steps to prevent preterm labor and delivery, including the following:
   1. Symptoms of preterm labor
   2. Self-detection of preterm labor
   3. Treatment
   4. Preventive measures

Prenatal Care Health Education II: Lifestyle & Parenting Support (H1003)

Lifestyle and Parenting Support educational services supplement the Prenatal Health Education I services and are necessary for a pregnant person who requires more time and specialized education to promote a healthy pregnancy lifestyle. Lifestyle changes resulting from this early and consistent education may have long-term effects on improving the health of the pregnant person, baby, and subsequent pregnancies.

Topics addressed in Prenatal Health Education II will depend upon the individual needs of the high-risk pregnant person. They may include the following:

• Education on the effects of smoking, alcohol, and other substances on birthing people and fetal development
• Smoking, alcohol, and other substance cessation or harm reduction education
• Referral to a support program
• Education on safe use of over-the-counter (OTC) medications and prescription drugs, including the need to consult with a primary provider before using any type of medication during pregnancy
• Environmental and occupational hazards (for example, lead)
  • Identify potential exposure to hazard in person’s own environment
  • Effects on fetal growth and development
  • Efforts to minimize exposure
  • Referrals for follow-up if needed
• Stress management
  • Identification of potential stressors in the person’s life: job, unemployment, school
  • Self-identification of signs of stress
  • Relaxation techniques
  • Referral to support services when appropriate
  • Coping skills
• Communication skills and resources
  • Family support systems
  • Health care providers
• Building self-esteem
• Parenting skills to meet the physical, emotional, and intellectual needs of the infant; bonding
• Identification and affirmation of positive prenatal parenting
  • Infant needs and cares
  • Nurturing
  • Infant feeding preparation
  • Referral to community resources if needed
• Planning for continuous, comprehensive pediatric care following delivery

Documentation Requirements for Prenatal Health Education I and II

Documentation requirements include: Evidence that education, information, or both was provided; amount of time spent, materials used, notes about the person’s reactions to information; review of information at subsequent visits; dates and names of people providing the service; referrals; and follow-up.

Prenatal Nutrition Education (H1003)

Prenatal Nutrition Education includes nutritional assessment and education that identifies nutritional risks and problems that the pregnant person may already have or be in danger of developing. Develop an individualized nutrition care plan for each high-risk pregnant person based on the assessment of their nutritional status and address the prevention and resolution of identified risks and problems. Incorporate the nutrition care plan into the overall individualized plan of care.

Nutrition interventions include individual or group (or both) nutrition education and provide information that will assist the pregnant person in making informed nutritional choices and accept responsibility to change nutritional behaviors to support a healthy pregnancy.

Prenatal nutrition education includes the following:

• An initial assessment of “nutritional risk” based on height, current and pre-pregnancy weight, laboratory data, clinical data, and self-reported dietary information
• Ongoing assessment of the pregnant person’s nutritional status (at least once every trimester) based on dietary information, measures to assess uterine and fetal growth, laboratory data, and clinical data
• Development of an individualized nutrition care plan that addresses the person’s nutritional needs, and proposes interventions and time frames with expected outcomes
• Referral to food assistance programs, if indicated (Women, Infants, and Children [WIC], food support, Mothers and Children Program, or similar programs)
• Nutritional interventions and education including the following:
  • Nutritional requirements of pregnancy and how nutrition is linked to fetal growth and development
  • The nutritional needs of the baby during pregnancy
  • Recommended weight gain for pregnancy
  • Importance of vitamin and iron supplements and recommendations for taking them
  • Infant nutritional needs and feeding practices, including benefits of breastfeeding
  • Incorporation of prenatal and postnatal exercise and physical activity when not contraindicated

Documentation Requirements for Prenatal Nutrition Education

• A written assessment of the person’s nutritional status and evidence of ongoing assessment and monitoring of their nutritional status
• A written, individualized nutritional care plan indicating proposed interventions, time frames, expected outcomes, and evidence of monitoring and ongoing evaluation of the care plan
• Evidence that education and information on nutrition was provided, materials used, amount of time spent, notes about the person’s reactions to the information, review of information at subsequent visits, dates and people providing the service, referrals, and follow-up.

Postpartum Follow-Up Home Visit (H1004)

The postpartum follow-up home visit is in addition to and separate from the member’s six-week postpartum visit to their primary care provider. It is to be completed within the first two weeks of the member’s hospital discharge.

This visit gives special support to high-risk members and infants by following up on identified high-risk behaviors or medical conditions, and addressing the stress involved in caring for a new baby. It is an opportunity to provide the following:

• Reinforcement and support for positive parenting skills
• Family planning counseling
• Anticipatory guidance for healthy parenting
• Education about infant care

The home visit assesses any needs of the family that will require additional home visits or referrals to appropriate health and social service providers. Services include the following:

• Assessment of the member’s health
  • Follow-up on risks and medical conditions
  • Reinforcement of positive behavior and lifestyle changes
• Physical and emotional changes occurring during the postpartum period
  • Anticipatory guidance regarding relationship with partner
  • Sexuality
  • Potential stress with family
  • Nutritional needs
  • Physical activity and exercise
• Contraceptive education
• Parenting skills and support
  • Adapting to parenthood
  • Parent and child relationship; bonding
  • Child care arrangements and support
• Grief support if unexpected outcome
• Parenting a sick or preterm infant, if indicated
  • Follow-up on risk factors and conditions
• Assessment of infant’s health
  • Infant weight and growth
  • Infant development and abilities

Documentation Requirements for Postpartum Follow-Up Visit

• Written assessment of member’s and infant’s health and the home environment
• Documentation that education or information on nutrition was provided and evidence of materials used, amount of time spent, notes about the member’s reactions to the information, review of information at subsequent visits, dates and people providing the service, referrals, and follow-up
• Documentation of all referrals made, and follow-up on those referrals
• Infant care
  • Feeding and infant nutritional needs
  • Recognition of illness in the newborn
  • Accident and injury prevention
  • Immunizations and pediatric care
  • Child and Teen Checkups (C&TCs)
• Identification and referral of community health and social service resources and assessment of need for additional home visits for either the birthing person or infant

Billing for Enhanced Services

1. Bill each enhanced service once per member per pregnancy.
2. Enhanced services will be paid only for a high-risk pregnant person (high-risk status must be established by prenatal screening). Screen all pregnant PrimeWest Health members using a standardized prenatal assessment tool (e.g., ACOG’s Obstetric Medical History), or an assessment tool that is developed or customized in the provider’s office and is equivalent to one of the standardized tools to determine high-risk status.
3. Maintain a copy of the prenatal risk assessment in the member’s record and send a copy to the PrimeWest Health Maternal Child Care Coordinator.
4. The primary provider may contract or refer the enhanced services to other PrimeWest Health-enrolled providers. In this case, the enrolled provider performing the service may bill PrimeWest Health directly using the 837P claim format with the codes listed in this section.
5. The primary provider may contract or refer enhanced services to providers not enrolled in PrimeWest Health (i.e., RN or nutritional counselor). In this case, the primary provider is responsible for billing PrimeWest Health for all services provided and paying the provider(s) who performed the services.
6. Physician extender modifiers are not required when billing for enhanced prenatal services.

Covered Services

Breast Pumps

Codes: E0602, E0603, E0604

PrimeWest Health covers breast pumps when ordered by a physician, CNM, or NP for any nursing person separated from their infant because of work, school, illness, or any other medical reason (refer to Equipment and Supplies Covered Services). PrimeWest Health pays for rental of hospital-grade breast pumps.

Screening Ultrasound in Uncomplicated Pregnancy

PrimeWest Health allows a single screening ultrasound (ideally conducted at 16 – 20 weeks gestation) per pregnancy to evaluate gestational age and anatomy, detect multiple pregnancies, and to evaluate potential abnormalities. Additional diagnostic ultrasounds are covered only as medically necessary. Indications supporting medical necessity for additional ultrasounds include, but are not limited to, the following:

1. Abnormal pregnancy serum analytes
2. Adjunct to:
   1. Amniocentesis, chorionic villus biopsy, fetal blood sampling
   2. Cervical cerclage placement
   3. External cephalic version
   4. Localization and removal of an intra-uterine contraceptive device
   5. Special diagnostic or therapeutic procedures on the fetus
3. Completion of anatomical screen for inadequate visualization of fetal organs
4. Confirm fetal viability or fetal death
5. Diabetes or gestational diabetes
6. Diagnosis of Zika virus
7. Evaluation of:
   1. A pelvic mass
   2. Incompetent cervix and/or risk of preterm delivery
8. Fibroid uterus
9. Follow-up of observed fetal anomaly
10. History of previous congenital anomaly
    1. Hyperemesis
    2. Hypertension, essential and pregnancy induced
    3. Identification and follow-up of placenta previa
11. Nonreactive nonstress test (NST)
12. Post-term pregnancy
13. Rh-sensitization or isoimmunization
14. Serial evaluation of fetal growth in multiple gestation
15. Significant uterine size and dates discrepancy
16. Suspected:
    1. Abruptio placentae
    2. Ectopic pregnancy
    3. Hydatidiform mole
    4. Oligohydramnios or polyhydramnios
    5. Uterine abnormality
17. Vaginal bleeding

Physician Standby Attendance for Newborn

PrimeWest Health will cover a pediatric standby when there is fetal distress. The following are examples of fetal distress that may warrant a pediatric standby:

1. Fetal bradycardia
2. Diabetes in the birthing person
3. Meconium
4. Premature labor
5. Foul-smelling amniotic fluid
6. Birthing person taking certain medications

If the pediatrician bills for standby services, the reason(s) for the pediatrician giving unusual services to the infant must be thoroughly documented.

Conditions such as prolonged labor, failure to progress, and cephalopelvic disproportions are generally not reasons for billing physician standby services unless fetal distress is also a factor.

Obstetric Services

Obstetric care can be billed either globally or by components. The billing method used is the provider’s choice, but only one method can be used for each obstetric case. Follow CPT guidelines for global and component billing.

The following must be true for services paid independently of the component and global methods:

• Do not bill the CPT obstetric panel code unless all components of the laboratory panel are performed
• If all components of the panel are not performed, bill the individual laboratory procedure codes that are CLIA-approved to bill. Refer to Laboratory/Pathology, Radiology and Diagnostic Services
• Miscellaneous services (for example, amniocentesis, ultrasound, fetal non-stress test, fetal Fibronectin, oxytocin challenge, estriol) must be billed with the appropriate codes
• Bill pregnancy and non-pregnancy-related services on separate invoices using appropriate ICD-CM diagnoses
• When billing the global bundle code, bill any services above and beyond a routine pregnancy separately from the bundle
• PrimeWest Health no longer pays a higher rate for vaginal deliveries for people who previously delivered by Cesarean section (VBAC). Use the appropriate CPT procedure code
• Bill vaginal delivery of multiple gestation births using modifier 22 with the appropriate CPT procedure code
• Bill Cesarean section done in response to an emergency using the ET modifier with the appropriate CPT procedure code
• Bill newborn services using the newborn’s PrimeWest Health member ID number and date of birth. This includes normal newborn care and any inpatient services to the newborn, whether before or after the birthing person’s discharge
• Bill the birthing person’s services using the birthing person’s PrimeWest Health member ID number
• Refer to Inpatient Hospital Authorization for billing instructions when a newborn is transferred to another facility for specialty services
• PrimeWest Health covers male circumcision only when the procedure is medically necessary
  • Circumcision is not covered in the newborn period (up to 28 days of life). Circumcision after the newborn period requires a Service Authorization for determination of medical necessity.
• Long-acting reversible contraceptives are billable outside of the hospital labor and delivery bundle

Human Immunodeficiency Virus (HIV) Counseling and Testing for Pregnant People

General Information

PrimeWest Health follows the recommendations of the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), ACOG, and MDH, which advocate HIV testing for all pregnant people.

PrimeWest Health recommends that all pregnant members receive screening, education, counseling, and voluntary testing for HIV at the first prenatal visit to ensure timely and therapeutic reproductive decision making. Advances in the treatment of HIV infection, and progress in reducing the transmission of HIV infection to newborns, makes early intervention crucial. HIV screening, education, counseling, and testing is reimbursed in addition to routine prenatal care. Physician extenders may provide HIV counseling to pregnant people within their scope of practice.

Keep a consent form or passive consent notification for HIV testing in the medical record. If the member refuses HIV testing after counseling, document the refusal in the medical record. Counseling, screening, and education for HIV will be reimbursed if provided, whether or not the member consents to have HIV testing. Testing will be reimbursed when consent is given and the testing is complete.

Inform HIV-positive pregnant people of their treatment options and of the related HIV services that are available. For more information, call the HIV/AIDS Unit of DHS (commonly called Program HH) office at 1-651-431-2414 or 1-800-657-3761 (toll free).

Voluntary Testing: A member consents to HIV testing after they have received pretest counseling, is informed of their right to refuse HIV testing, is informed that their refusal will not jeopardize their health benefits, and does not refuse the testing.

Pretest Counseling: Includes the following components:

1. Explanation of what HIV is
2. Risk factors for HIV infection and how the virus is transmitted
3. Treatment available for HIV-positive members during pregnancy and after delivery
4. Risk factors for the newborn
5. Treatment options for the newborn
6. Rights of the pregnant person to choose testing
7. Explanation of who has access to test results and confidentiality
8. HIV risk assessment

Post-test Counseling: Includes the following components:

• Give and explain test results
• Risk factors for HIV infection and how to reduce the risk of infection
• If HIV test results are positive, referrals for additional services and information about treatment options
• Information about how the virus is transmitted and how to reduce the risk of transmission
• If HIV test results are positive, counseling and referrals related to health issues for partner(s) and children that may have been infected
• Information about the need for repeat follow-up testing whether the results are positive or negative
• Referral for case management services for HIV-positive members and their newborns
• Referral to local community support services such as Minnesota AIDS Line (Twin Cities Metro area: 1-612-373-AIDS (2437) (voice) or TTY 1-612-373-2465; statewide: 1 800-248-AIDS (2437) (voice) or TTY 1-800-627-3529.

Informed Consent: The member received the following information:

1. That HIV testing is voluntary
2. The entities who have access to HIV test results (such as third-party payers or Public Health agencies)
3. When, and under what circumstances, this information can be released (such as a legal subpoena)

Confidentiality: Documentation indicating that HIV test results are private. Confidential HIV information can be released only to individuals or entities with the written permission of the member. The member must be informed about the law that allows the release of the HIV test results (without permission) under limited circumstances.

Positive Test: A test result that is positive for the HIV antibody.

Negative Test: A test result that is negative for the HIV antibody. Additional follow-up testing, especially for members with known recent HIV exposure or with continued risk behaviors, may be needed to determine recent infection.

Follow-Up: Follow-up health services provided to HIV-positive members and their infants must include the following:

1. Review of what it means to be HIV positive (it does not mean that they have AIDS, but it does mean they can infect others)
2. Ongoing lab tests to evaluate immune system function
3. Ongoing counseling regarding HIV status and treatment options
4. Emphasis on the need for good health practices
5. Information about current treatment practices to reduce the risk of transmission of HIV and to promote the health of the member
6. Information that a positive HIV test result can mean that children and partners could be infected with HIV and that those individuals should be referred for medical testing and follow-up
7. Information that a baby born to an HIV-positive member should receive regular medical care from a physician who is knowledgeable about HIV treatment to ensure appropriate care
8. Information that all babies are born with the birthing person's antibodies and many months of follow-up are required to determine the newborn’s HIV status. If a baby is not infected, the HIV test will be negative by 18 – 24 months.
9. Discussion with people who are breastfeeding or considering breastfeeding of the risk of transmission of HIV through breastfeeding (the CDC recommends that HIV-positive people not breastfeed)
10. Emphasize that HIV is not spread through casual contact

Providers

A physician, CNM, DO, PA, CNP, licensed RN, and other physician extenders may provide HIV counseling to pregnant women within their scope of practice.

Billing

1. PrimeWest Health pays for HIV screening, education, counseling, and testing in addition to routine prenatal care when appropriate CPT codes are used.
2. Providers must bill on the 837P claim format and use the appropriate continuation CPT codes for services related to HIV screening, education, testing, and counseling.
3. Physician extenders must use the appropriate modifier.

Non-Covered Services

PrimeWest Health does not cover services related to surrogate pregnancies.

Telehealth Services

Telehealth services are covered for PrimeWest Health members. Providers must submit a completed and signed Telehealth Provider Assurance Statement (DHS-6806) to the Minnesota Department of Human Services to bill for telehealth services. Review the Telehealth Services section for more information. 

Abortion-Related Services

Abortion-related services are services directly related to performing an induced abortion. Examples of abortion-related services include the following:

• Hospitalization when the abortion is performed in an inpatient setting
• The use of a facility when the abortion is performed in an outpatient setting
• Counseling related to the abortion
• General or local anesthesia provided in conjunction with the abortion
• Drugs provided during or directly after the abortion (treatment of infection or other complications as a result of the abortion is a covered service)
• Uterine ultrasound, performed immediately following abortion
• Abortion service codes (surgical induced abortion and medical abortion service codes)
• Supplies (trays, laminaria, etc.)
• Drugs (anti-anxiety, narcotics, anesthetics, antibiotics, etc.)
• Cervical block and/or related services.

Covered Non-Abortion-Related Services

PrimeWest Health covers the following non-abortion-related services (this list is not all-inclusive):

• A history and physical exam performed on the same day as the procedure
• Tests for pregnancy and venereal disease
• Blood tests
• Rubella titre
• Gonadotropin levels (hCG)
• Hemoglobin (Hgb) and hematocrit (HCT)
• The GAM (TM)
• A Pap smear
• Laboratory examinations for the purpose of detecting fetal abnormalities
• Family planning services provided as a separate service
• Uterine ultrasound to confirm pregnancy
• RhD drugs
• Drugs used in conjunction with pregnancy, or post-pregnancy state

Billing

• Induced abortion and induced abortion-related services may not be billed to PrimeWest Health – bill Minnesota Health Care Programs (MHCP).
• Services not related to an induced abortion (e.g., family planning, contraceptive management) should be billed to PrimeWest Health with the appropriate diagnosis. Do not include induced abortion services or induced abortion-related services or induced abortion diagnosis codes on the claim. Claims with these services or codes will be denied.
• Bill pregnancy-related services performed prior to, on the day of, or after an induced abortion to PrimeWest Health.
• Bill non-induced abortion services with the correct diagnoses (e.g., pregnancy with fetal demise, missed abortion, spontaneous abortion) to PrimeWest Health.
• Only pharmacy claims for mifepristone and misoprostol may be billed to PrimeWest Health. 

Home Birth

Overview

PrimeWest Health covers low-risk pregnancy and low-risk delivery services provided at home when PrimeWest Health home birth policy requirements are fulfilled.

Eligible Providers

Eligible providers, when home birth is in their scope of practice and experience, include the following:

• Certified professional midwife
• Certified nurse midwife
• Physician

Providers must be enrolled with MHCP and be working within their scope of practice as defined by Minnesota law. 

Eligible Members

All members with Medical Assistance or MinnesotaCare fee-for-service coverage are eligible to receive home pregnancy and birth services if they are determined to be at low-risk for pregnancy and delivery complications. Low risk means a routine, uncomplicated prenatal course as determined by documentation of adequate prenatal care and the anticipation of a routine, uncomplicated labor and birth, as defined by reasonable and generally accepted criteria adopted by professional groups for maternal, fetal, and neonatal health care.

Covered Services

PrimeWest Health covers prenatal, delivery, postpartum and newborn care for pregnant people that are considered at low-risk for adverse birth outcomes. Covered services include the following, which may be conducted in the home as appropriate:

• Prenatal visits
• Laboratory services
• Ultrasound
• Low-risk labor and delivery
• Postpartum visits
• Lactation services
• Newborn care services
• Care during labor until hospital transfer is covered (if needed)
• Telehealth visits where appropriate

Coverage Limitations

Providers should consult another provider with more experience when potential concerns of adverse outcomes develop to determine the appropriateness of continued care versus transferring to a higher level of care or hospital for birth.

Diagnoses that would not qualify for a home birth include, but are not limited to, the following:

• Insulin-dependent diabetes
• Essential hypertension
• Active tuberculosis
• Placental abruption
• Insulin-dependent gestational diabetes
• Known fetal anomaly or condition that requires physician management during or immediately after delivery
• Hemoglobin less than 9 at 36 weeks (can return to out of hospital midwifery care if above 9 by onset of labor)
• Deep vein thrombosis or pulmonary embolism
• Placenta previa at term
• Low lying placenta within 2 cm or less of the opening at the cervix at 38 weeks 0 days
• Vasa previa
• Multiple gestation
• Prior cesarean with incision other than low transverse (for example, classical)
• Gestation less than 36 weeks and more than 43 weeks 0 days
• Active substance use disorder, including opioid and alcohol use disorder, but excluding tobacco or marijuana use
• Any other diagnoses or complications that are considered high risk according to reasonable and generally accepted criteria adopted by professional groups for maternal, fetal, and neonatal health care

Plan of Care

Each member’s plan of care should include the following:

• Consent form detailing the risks and benefits of home birth signed by the member
• Recommended test results and sufficient visits to establish the member is low risk
• Consultations that occurred (when needed) to re-affirm the low-risk status of the member
• A plan for immediate safe transfer of care to a hospital in the event a need for a higher level of care develops

Noncovered Services

• Services provided by an unlicensed midwife
• General or regional anesthesia
• Pregnancies that are considered high risk

Billing

Refer to applicable billing requirements for an overview of PrimeWest Health billing policies and procedures, which include the following:

• Bill electronically using the 837P Professional format
• Bill the newborn services using the newborn’s PrimeWest Health member ID (subscriber ID) number and the birthing person’s services using the birthing person’s PrimeWest Health ID number (subscriber ID). Refer to Obstetric Services in the MHCP Provider Manual for more information on billing processes that may be applicable.
• Bill newborn services using the newborn’s PrimeWest Health member ID number (subscriber ID) and the birthing person’s services using the birthing person’s PrimeWest Health member ID number 
• Home birth supplies should be billed with code S8415 and are paid at 70 percent of the uncomplicated vaginal birth reimbursement rate for hospitals. The newborn screening card is included in the rate; do not bill separately. 
• If a member is transferred to the hospital for delivery, bill home birth supplies with code S8415 with modifier U5. This reimbursement rate is 15 percent of the uncomplicated vaginal birth reimbursement rate for hospitals. The newborn screening card is not included in the rate. If the newborn screening is provided by the home birth midwife and not the hospital, bill code S3620 separately.

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Updated_06/30/2026