Policies & Guidelines
- Compliance
- Definitions
- Ambulatory Surgical Services
- Billing Policy
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Legal References
-
- Ambulatory Surgical Services
- Billing Policy
- CFSS
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- Equipment and Supplies
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Member Eligibility
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Quality: HEDIS
- Policies & Procedures
Service Authorization
Definitions
Service Authorization: The approval and issuance of an authorization number by a medical review agent under contract with PrimeWest Health.
State Appeal (Medicaid Fair Hearing with the State): An administrative proceeding to examine facts concerning the matter in dispute and to advise the Commissioner if the decision to reduce or deny benefits is appropriate.
Investigative Health Service: A procedure that has limited human application and trial and lacks wide recognition as a safe and effective procedure in clinical medicine. A drug or device (identified in the Food, Drug, and Cosmetic Act) the United States Food and Drug Administration (FDA) has not yet declared safe and effective for the use prescribed.
Local Trade Area: The geographic area surrounding a member’s residence commonly used by local residents to obtain similar health care services.
Medical Necessity: A health service that is consistent with the member’s diagnosis or condition and is:
- Recognized as the prevailing medical community standard or current practice by the provider’s peer group; and
- 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
- Is a preventive health service as defined in MN Rules part 9505.0355.
Out-of-State Provider: A provider located outside of the State of Minnesota and the member’s local trade area.
Referee: A person who conducts fair hearings and provides recommendations to the Commissioner.
PW_03-19_147
Updated_12/22/2021
