Out-of-Network Facility Registration Requirements

If you are a new provider to PrimeWest Health (i.e., you have not contracted to be part of our network) and need to submit a claim or payment request for health care services or supplies as an out-of-network provider, you must submit the following forms for provider set-up before we can process your claims.
 

Note: Forms must be downloaded before they can be completed and submitted. To download a form, right-click on the name of the form, choose “Save target as” or “Save link as,” select a folder on your computer, and click the “Save” button. After the form has finished downloading, navigate to the folder it was saved to and double-click it to open it in Adobe Reader. Failure to download the document prior to completing it will result in the document sending as a blank PDF without signatures.
 

For information on Service Authorization requirements, review the Service Authorization and Out-of-Plan Providers sections of the Provider Manual.

Non-Contracted Facility Information
PrimeWest Health requires all facilities to register prior to submitting claims. As part of the registration process, please complete the Non-Contracted Facility Information Form and include all requested information. This form enables PrimeWest Health to add your facility to our claims processing system in a timely and accurate manner. PrimeWest Health will not accept claims electronically prior to receiving this information from your facility.

Completion of all forms is required for PrimeWest Health to process claims and indicates a non-contracted facility is attesting that it will comply with PrimeWest Health’s billing requirements identified in our Provider Manual as well as comply with all Federal and State laws regarding billing.

Practitioner NPI/UMPI Notification/Request
We are required to collect information on practitioners providing services at non-contracted facilities. Please complete the Practitioner NPI/UMPI Notification/Request form for all practitioners providing services billable to PrimeWest Health. The information will be added to our claims processing system to process submitted claims. The Practitioner NPI/UMPI Notification/Request form requires inclusion of a Social Security number (SSN). This will be shared with the State of Minnesota for reporting purposes only. 

  • If your claim requires a referring or ordering provider, please verify that the provider is eligible to refer or order.
  • If the services are Medicare-covered, the referring/ordering provider needs to be enrolled with the Centers for Medicare & Medicaid Services (CMS) or have opted out of enrollment with CMS. (If provider has opted out, include the affidavit with the claim.) 
  • If the services are covered by Minnesota Medical Assistance (Medicaid), the referring/ordering provider needs to be registered with Minnesota Health Care Programs (MHCP).

W-9
In compliance with Internal Revenue Service (IRS) regulations, PrimeWest Health requests that you also provide a completed W-9 form. Please pay particular attention to the following with respect to the Individual Taxpayer Identification Number (TIN):

  • When including an SSN: Only the name of the person whose SSN is included should be entered on the first line. Include the last name, first name, and middle initial; OR
  • When including an Employer Identification Number (EIN): The name of the partnership, corporation, sole proprietorship, club, or other entity must be entered on the first line exactly as it was registered with the IRS when the Federal EIN was assigned.

Please do not submit a TIN that has not been assigned to your name. For example, a health care provider who submits his/her name on a W-9 must use his/her own SSN. If a health care provider uses the clinic name, then the W-9 must contain the Federal EIN of the clinic. Only one TIN can be submitted on the form. Do not list both an SSN and an EIN.

ERA and EFT
Electronic Remittance Advices (ERA) was mandated by MN Stat. sec. 62J.536, which requires all providers in the State of Minnesota to receive explanations of payment (EOPs) electronically after December 15, 2009. ERA is a timesaver, both in terms of posting payments and accuracy. PrimeWest Health requires all Minnesota providers to register to receive their ERA 835 remittances through their clearinghouse or to retrieve them via the PrimeWest Health provider web portal. Both ERA options require the provider to complete the ERA Authorization Agreement. PrimeWest Health recommends that providers sign up to have claim payments automatically deposited into their bank account by completing the EFT Authorization Agreement. Both of these forms can be completed and submitted through our provider web portal. If you are not registered for the provider web portal, you can request access. Minnesota providers failing to complete and return the ERA form will be set up to retrieve EOPs from our provider web portal.

Submitting required documentation
As a Managed Care Organization (MCO) contracted with the Minnesota Department of Human Services (DHS) to administer health care benefits, we are required to submit certain provider information to the State. Failure to provide the Non-Contracted Facility Information Form, Practitioner NPI/UMPI Notification/Request form (if applicable), and W-9 form will result in the denial/rejection of your claims. If you receive a claim denial or rejection and you then submit the required information, you must also resubmit your denied/rejected claim. Please allow 15 business days between submitting the required information and resubmitting your claim.

Please return all forms even if you are exempt from backup withholding, and make sure you complete all forms in their entirety and in accordance with the instructions. The forms must be completed in a legible manner and should contain accurate and current information. The EFT Authorization Agreement must be mailed or submitted via the provider web portal. Please return all other completed forms by fax to 1-320-762-1805, by email to claims@primewest.org, or by mail to:

Claims Department – Accounts Payable Coordinator
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

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Updated_11/30/2023