Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
- Community First Services and Supports (CFSS)
- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
- HCBS
- Hearing Services
- Home Care Services
- Hospice Services
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
- Personal Care Assistance (PCA) Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitation Services
- Renal Dialysis
- Restricted Recipient Program
- School-Based Community Services
- Substance Use Disorder
- Telehealth Services
- Transportation
- Tribal and Federal Indian Health Services
- Dental
- Pharmacy
Skilled Nurse Visits (SNVs)
Eligible Members
- Medical Assistance (Medicaid) members
- MinnesotaCare Expanded Benefit Set (children under age 21, and pregnant women)
- MinnesotaCare Basic, Basic Plus, Basic Plus One, or Basic Plus Two coverage
Eligible Providers
Medicare-certified, Comprehensive licensed home health agencies enrolled with PrimeWest Health.
PrimeWest Health covers two visits per day. If the necessary medical services are more complex and require more time than can be performed in a single or twice daily SNV, HCN services are an appropriate option.
Waiver recipients require prior authorization from the county case manager.
Services cannot begin before the date PrimeWest Health receives the complete Service Agreement request with all corresponding documentation. Refer to the Information for All PrimeWest Health Home Care Providers section for more information.
Covered Skilled Nursing Services
- An SNV is made according to the member’s written plan of care or service plan, ordered by the physician, and is an accepted standard of medical and nursing practice in accordance with the Minnesota Nurse Practice Act (MN Stat. sec. 148.171, subd. 1). Equipment and supplies that are usual and customary (U&C) to completing an SNV are not billable (e.g., stethoscope, nail clippers, sphygmomanometer, alcohol wipes, etc.).
- Intermittent home visits to initiate and complete professional nursing tasks based on a member’s need for service as assessed to maintain or restore optimal health. Visits are made by an RN or LPN employed by a Medicare-certified home health agency, under the supervision of an RN. If the necessary medical services are more complex and require more time than can be performed in a single or twice daily SNV, HCN services are an appropriate option.
- Observation, assessment, and evaluation of a person’s physical or mental health status. These may be covered when the likelihood of a change in condition requires skilled nursing personnel to identify and evaluate the need for possible modification of treatment or initiation of additional medical procedures until the member’s treatment regimen is stabilized.
- A procedure that requires substantial and specialized nursing skill such as administration of intravenous therapy, intra-muscular injections, and procedures, such as sterile catheter insertion or sterile wound cares.
- Teaching and training that requires the skills of a nurse. Examples could include: teaching self-administration of injectable medications or a complex range of medications, teaching a newly diagnosed diabetic person or caregiver on all aspects of diabetic management, teaching self-catheterization or bowel and/or bladder training.
- Postpartum visits to new mothers and their newborn infants if the mother and her newborn are discharged early from the hospital. Early discharge means less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean section. Post-delivery care includes a minimum of one home visit by a licensed RN. The RN must provide parent education, assistance, and training in breast and bottle-feeding and conduct any necessary and appropriate clinical tests. The licensed RN must make the home visit within four days following hospital discharge. A separate plan of care is needed for the mother and newborn.
- Community health nursing visits provided by a public health agency or home health agency for the sole purpose of maternal, child, and adult health promotion are covered when an authorized skilled nursing service is provided at the same visit.
- Two visits per day when necessary.
- Telehome-care visits. Coverage of telehome-care is limited to two visits per day.
- Venipuncture from a peripheral site is covered if the home health provider has determined and documented the following:
- That there is not an available lab service that can visit the member’s home to obtain the venipuncture from the peripheral site
- That there is not a service reasonably available to the member outside of their place of residence
- The member no longer qualifies for Medicare Part A skilled Medicare services (this may include physical therapy without SNVs)
Non-Covered SNVs
Home Visits
- Usual and customary (U&C) equipment and supplies that are necessary to complete an SNV (e.g., stethoscope, nail clippers, sphygmomanometer, alcohol wipes, etc.).
- Home visits made for the sole purpose of supervising an HHA or PCA/CFSS. However, supervision may be done during an SNV that qualified for payment.
- Home visits made for the sole purpose of monitoring medication compliance with an established medication program for a member.
- Home visits made for the sole purpose of monitoring a member’s overall physical status, when the member’s physical status has not changed and the person is considered stable.
- Home visits made to set up or administer oral medications; pre-fill injections, such as insulin syringes for an adult member when the need can be met by an available pharmacy; or the member is physically and mentally able to self-administer or pre-fill a medication; or if the activity can be delegated to a family member or HHA.
- Home visits when the sole purpose of the visit is to train other home health agency workers.
- Home visits when the visit is performed in a place other than the member’s residence.
- Home visits made for Medicare evaluation or administrative nursing visits required by Medicare but not qualifying as an SNV (these visits are an administrative expense for the Medicare-certified agency and cannot be billed to PrimeWest Health).
- Home visits by a licensed RN who makes an SNV but is employed by a PCPO or non-Medicare HCN agency.
- A communication between the home care nurse and member that consists solely of a telephone conversation, facsimile, or electronic mail or a consultation between two health care practitioners is not considered a telehome-care visit.
Discontinuing Care to a Member
If a home care provider determines it is unable to continue providing care to a member, the provider must notify the member, responsible party, and PrimeWest Health at least 30 days before terminating services and assist the member in transitioning to another home care provider. If the termination is a result of sanctions on the provider, the provider must give each member a copy of the Home Care Bill of Rights at least 30 days before terminating services (Minnesota 2010 Session Law, Chapter 352, article 1, section 8).
Intermediate Care Facility for the Developmentally Disabled (ICF/DD) Skilled Nurse Visits (SNVs)
PrimeWest Health may cover SNVs for fewer than 90 days for a member residing in an ICF/DD to prevent admission to a hospital or NF, if the ICF/DD is not required to provide the nursing services.
A skilled nurse may be authorized for venipuncture if none of the above conditions can be met. This must be documented in a clinical update on a CMS-485 or CMS-486. See also Chapter 6 of the Medicare Program Integrity Manual.
Telehome-Care
- A telehome-care visit is an SNV that is made via live, interactive audiovisual technology between the home care nurse and the member. It can also be augmented by utilizing store-and-forward technology, which is a technology that does not occur in real time via synchronous transmission and does not require a face-to-face encounter with the member for all, or part of, any such telehome-care visit.
- T1030-GT is the code for home telehealth face-to-face “live” (SNV).
- A communication between the home care nurse and member that consists solely of a telephone conversation, facsimile, or electronic mail or a consultation between two health care practitioners is not considered a telehome-care visit.
- Coverage of telehome-care is limited to two visits per day.
- Home health for peripheral only (weight, pulse, oximetry, etc.), use the code 99091 (the code 99091 can be billed four times within the month [i.e., once per week]).
- Bill using code E1399-52 for equipment used for peripheral telehome-care visit.
Skilled nursing services are covered when such skilled nursing services are necessary to maintain the member's current condition or prevent or slow further deterioration so long as the member requires skilled care for the services to be safely and effectively provided.
Skilled therapy services are covered when an individualized assessment of the member's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist ("skilled care") are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the member's current condition or to prevent or slow further deterioration is covered so long as the member requires skilled care for the safe and effective performance of the program.
PW_11-19_551
Updated_02/25/2025
