Billing Guidelines

1. Room and board services must be billed in the 837I format using the facility’s National Provider Identifier (NPI). The type of bill must be 28
2. The daily room and board payment rate for Swing Bed services is set by law as the statewide average payment rate of all Medical Assistance (Medicaid) nursing facilities’ per diem. This rate is computed annually, effective each July 1.
3. Only non-OTC PrimeWest Health formulary pharmacy services can be billed outside the room and board per diem. Stock medications and OTC products are not separately reimbursable.
4. Ancillary services for PrimeWest Senior Health Complete/Prime Health Complete-eligible members must be billed to PrimeWest Health. If the services are not covered by Medicare, PrimeWest Health may be billed under the member’s Medicaid benefit.
5. Ancillary services for Medicare-eligible members not on a PrimeWest Health Medicare Advantage Plan must be billed to Medicare. If the services are not covered by Medicare, PrimeWest Health may be billed under the member’s Medicaid benefit.
6. Bill type 210 is not required for PrimeWest Senior Health Complete or Prime Health complete members as PrimeWest Health pays both portions (Medicare and Medical Assistance [Medicaid]) of the claim.
   1. The 60-day break in spell of illness is tracked in the PrimeWest Health web portal
7. Demand Bill: Member is entitled to receive one if he/she requests it.
8. Shadow Billing: Medicare requires a claim for skilled days to track the number of days used. This will need to be submitted to Centers for Medicare & Medicaid Services (CMS).

For nursing home residents who have exhausted their 180 days of managed Medical Assistance (Medicaid) days, the nursing facility provider must update the notification form using the PrimeWest Health web portal to notify PrimeWest Health of this change. PrimeWest Health will notify DHS.

PrimeWest Health uses Minnesota Department of Human Services (DHS)/Minnesota Department of Health (MDH) Nursing Home Report Card facility daily rates when processing Medical Assistance (Medicaid) long-term care claims. To prevent claims from denying due to missing Medical Assistance (Medicaid) resource utilization group (RUG) rates please fax Medical Assistance (Medicaid) RUG rates to 1-320-762-1805.

Equalization

State law prohibits nursing facilities from charging private-pay residents higher rates than those approved by DHS for Medicaid recipients. The law also allows residents to be awarded three times the payments that result from a violation. For more information on equalization and special services, refer to the Additional Charges for Special Services section in this chapter.

Exceptions

1. The Equalization Law does not apply to third party payers
2. The Equalization Law may or may not apply to private paying residents in single bed rooms, depending on the cost allocation method for single bed rooms chosen by the facility on their annual cost report

Patient Driven Payment Model (PDPM)

The Patient Driven Payment Model (PDPM) case-mix classification model is used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. PrimeWest Health follows CMS methodology for reimbursement of Medicare covered SNF stays. Refer to the CMS Patient Driven Payment Model web page for more information on the PDPM.

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Updated_11/07/2022