Requirements for Providers

Definitions

Abuse: In the case of a vendor, a pattern of practice that is inconsistent with sound fiscal, business, or health service practices, and that results in unnecessary costs to PrimeWest Health or in reimbursement for services not medically necessary, or that fail to meet professionally recognized standards for health services. The following practices are deemed to be abuse by a provider:

  1. Submitting repeated claims or causing a claim to be submitted:
  1. With missing or incorrect information;
  2. Using procedure codes that overstate the level or amount of health service provided;
  3. For health services that are not reimbursable by PrimeWest Health;
  4. For the same health service provided to the same member;
  5. For health services that do not comply with the requirements to be a covered service under MN Rules part 9505.0210 and, if applicable, MN Rules part 9505.0215;
  6. For services not medically necessary.
  1. Failing to develop and maintain health service records as required under MN Rules part 9505.2175;
  2. Failing to use generally accepted accounting principles or other accounting methods that relate entries on the member’s health service record to corresponding entries on the billing invoice, unless another accounting method or principle is required by Federal or State law or rule;
  3. Failing to disclose or make available to PrimeWest Health the member’s health service records or the vendor’s financial records as defined under MN Rules part 9505.2180;
  4. Repeatedly failing to report duplicate payments from third party payers for covered services provided to PrimeWest Health members and billed to PrimeWest Health;
  5. Failing to obtain information and assignment of benefits as specified in MN Rules part 9505.0070, subp. 3, or failing to bill Medicare as required by MN Rules part 9505.0440;
  6. Failing to keep financial records as defined under MN Rules part 9505.2180;
  7. Repeatedly submitting or causing repeated submission of false information for the purpose of obtaining Service Authorization, inpatient hospital admission certification, or a second medical opinion;
  8. Knowingly and willfully submitting a false or fraudulent application for provider status;
  9. Soliciting, charging, or receiving payments from members or non-Medical Assistance (Medicaid) sources, in violation of Title 42 Code of Federal Regulations (CFR) Part 447.15 or MN Rules part 9505.0225, for services for which the vendor has received reimbursement from, or should have billed to, PrimeWest Health;
  10. Payment of program funds by a vendor to another vendor whom the vendor knew or had reason to know was suspended or terminated from PrimeWest Health participation;
  11. Repeatedly billing PrimeWest Health for health services after entering into an agreement with a third party payer to accept an amount in full satisfaction of the payer’s liability;
  12. Repeatedly failing to comply with the requirements of the provider agreement that relate to the programs covered by MN Rules parts 9505.2160 – 9505.2245;
  13. Failing to comply with the ownership and control information disclosure requirements of 42 CFR 422.455;
  14. Billing for services that were provided to a member without the request or consent of the member, the member’s guardian, or the member’s responsible party; and
  15. Billing for the services that were outside the scope of the vendor’s license, or in the case of a provider that is not required to hold a license, billing by a provider for services that the provider is not authorized to provide under applicable regulatory agency requirements.

Electronically Stored Data: Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape, or computer disk.

Factor: An individual or organization that advances money to a provider for their accounts receivable for an added fee or a deduction of the accounts receivable worth. Payment for any covered service furnished to a member by a provider may not be made to or through a factor, either directly or indirectly.

Fraud: Acts that constitute a crime against any program, or attempts or conspiracies to commit those crimes, including the following:

  1. Theft in violation of MN Stat. sec. 609.52
  2. Perjury in violation of MN Stat. sec. 609.48
  3. Forgery and aggravated forgery in violation of MN Stat. sec. 609.625 and MN Stat. sec. 609.63
  4. Financial transaction card fraud in violation of MN Stat. sec. 609.821
  5. Medicare/Medicaid fraud
  6. Making a false statement, claim, or representation to a program where the person knows or should reasonably know the statement, claim, or representation is false
  7. A felony listed in Title 42 United States Code (USC) Section 1320a-7b(b)(3)(D) subject to any safe harbors established in 42 CFR 1001.952

Health Care Directive: A written instruction such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of care when the patient is incapacitated. The intent of a Health Care Directive is to enhance a patient’s control over medical treatment decisions. Health Care Directives are sometimes called Advance Directives.

Health Plan: A health maintenance organization (HMO), Managed Care Organization (MCO), or other organization that contracts with the Minnesota Department of Human Services (DHS) to provide health services to members under a prepaid contract.

Health Services: Goods and services eligible for PrimeWest Health payment under MN Stat. sec. 256B.02, subd. 8 and MN Stat. sec. 256B.0625.

Health Service Record: Electronically stored data and written or diagrammed documentation of the nature, extent, and evidence of the medical necessity of a health service provided to a member by a vendor and billed to PrimeWest Health.

Interpretation: The oral replacement of one spoken language (source language) into another spoken language (target language). Four modes of interpretation exist: consecutive, simultaneous, summarization, and sight translation (when the interpreter reads text in one language and speaks it in another language).

Investigative Costs: Investigative costs are subject to the provisions of MN Stat. sec. 256B.064, subd. 1d, and means the sum of the following expenses incurred by a PrimeWest Health investigator on a particular case:

  1. Hourly wage multiplied by the number of hours spent on the case;
  2. Employee benefits;
  3. Travel;
  4. Lodging;
  5. Meals; and
  6. Photocopying costs, paper, computer data storage or diskettes, and computer records and printouts.

Medical Necessity: A health service that is consistent with the member’s diagnosis or condition and is:

  1. Recognized as the prevailing medical community standard or current practice by the provider’s peer group; and
  2. Rendered in response to a life-threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve community standards for diagnosis or condition; or
  3. A preventive health service as defined in MN Rules part 9505.0355.

Minnesota Health Care Programs (MHCP): The Medical Assistance (Medicaid) Program, MinnesotaCare, Consolidated Chemical Dependency Treatment Fund (CCDTF), Prepaid Medical Assistance Program (PMAP), Home and Community Based Services (HCBS) under a waiver from the Centers for Medicare & Medicaid Services (CMS), or any other DHS-administered health service program.

Ownership or Control Interest: Has the meaning given in 42 CFR 455, subp. B.

  1. Physician-owned hospitals are required to disclose to their patients the names of the physician owners and the names of immediate family members of the physician who have an ownership or investment interest in the hospital.
  2. Physicians are required to disclose to their patients at the time of referral if they (or their immediate family members) have an ownership or investment interest in the hospitals to which they refer patients for treatment.
  3. Hospitals that fail to disclose this information to patients may lose their provider agreements to participate in the Medicare program, and physicians who fail to disclose this information to patients may lose their hospital medical staff memberships.
  4. As part of the credentialing process and at any other time upon request of PrimeWest Health, contracted providers shall provide the name, address, Social Security Number, and date of birth of all persons and businesses or organizations that meet the following criteria:
    1. Have an ownership or control interest of 5 percent or more in the disclosing entity
    2. Are a managing employee of the disclosing entity
    3. Have an ownership or control interest in a subcontractor in which the disclosing entity has a direct or indirect ownership interest of 5 percent or more

Patient: Any adult resident, patient, member, or client receiving medical care from or through the provider.

Pattern: An identifiable series of more than one event or activity.

Person with Limited English Proficiency (LEP): A person not able to speak, read, write, or understand English at a level that allows him/her to effectively interact.

Provider: An individual, organization, or entity that has entered into an agreement with PrimeWest Health for the provision of health services, including a Personal Care Assistant (PCA).

Restriction: In the case of a vendor, excluding or limiting the scope of the health services for which a vendor may receive a payment through a program for a reasonable time.

Suspending Participation or Suspension: Making a vendor ineligible for reimbursement through PrimeWest Health funds for a stated period of time.

Suspending Payments: Stopping any or all program payments for health services billed by a provider pending resolution of the matter in dispute between the provider and PrimeWest Health.

Terminating Participation or Termination: Making a vendor ineligible for reimbursement through PrimeWest Health funds.

Theft: The act defined in MN Stat. sec. 609.52, subd. 2 (3) (iii).

Third Party Payer: The term defined in MN Rules part 9505.0015, subp. 46, and, additionally, Medicare.

Translation: The written replacement of text from one language (source language) into an equivalent text in another language (target language).

Vendor: The meaning given to “vendor of medical care” in MN Stat. sec. 256B.02, subd. 7. The term vendor includes a provider and also a PCA.

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Updated_03/14/2019