Appeals

Appeal requests by a participating provider must be made within 90 days from the date the claim or Service Authorization request for covered services was denied by PrimeWest Health. Non-participating providers must make such an Appeal request within 60 days. PrimeWest Health will not make corrective adjustments after the allowed time frame. All providers must include documentation such as a copy of the original claim, the remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s argument for reimbursement.

PrimeWest Health provider Appeal requests must be submitted online through the PrimeWest Health provider web portal. All Appeal decision notifications can also be viewed in the portal. If you are not registered for the web portal, please create an account.

Pursuant to the Federal regulatory authorities, a non-participating provider, on his/her own behalf, is permitted to file a standard Appeal for a denied Medicare claim.

    Claims that are over 180 days

    1. Submit your claim to PrimeWest Health for Timely Filing denial.
    2. Appeal Timely Filing denial via the provider web portal only after the denial is received.
    3. The Appeal must be received within 90 days of the denial for Timely Filing.
    4. The Appeal must have appropriate, dated documentation attached. Documentation will be reviewed, but does not guarantee payment. Appropriate documentation may include, but is not limited to the following:
      1. Proof of eligibility verification through the EVS, MN–ITS, or the PrimeWest Health web portal
      2. Printout from provider’s Practice Management Software that confirms claim was submitted within 180 days of the date of service (DOS)
      3. Documentation of timely follow-up of the previous claim submission(s)
      4. Copies from the provider’s electronic data interchange (EDI) submission report indicating the claim was transmitted to and accepted by PrimeWest Health (Please note that your facility will usually receive two reports. The first will typically indicate that your claim was “Forwarded” to PrimeWest Health and the second should state that your claim was “Accepted” by PrimeWest Health.)
      5. Documentation that fully explains extenuating circumstances for the delay in claims submission

    Non-contracted providers

    1. Non-contracted providers have 60 calendar days from the remittance notification date to file the Appeal.
    2. Non-contracted providers must include a signed Waiver of Liability Statement holding the member harmless regardless of the outcome of the Appeal.

    Coordination of Benefits (COB)

    Providers may only Appeal to PrimeWest Health for payment after three unsuccessful attempts have been made to collect payment from a Third Party Liability (TPL) payer, except when the TPL payer has already made payment to the recipient. The Appeal must be submitted within 90 days of the last attempt made to the TPL payer. When submitting the Appeal, include the following:

    • A copy or screen print of the first claim sent to the TPL payer
    • Documentation of two additional billing attempts
    • Any written communication received from the TPL payer

    PrimeWest Health provider Appeal requests and supporting documentation must be submitted online through the PrimeWest Health provider web portal. Appeal decision notifications can also be viewed in the portal. If you are not registered for the web portal, please create an account.

    Claims must be billed to PrimeWest Health within 180 days of the last unsuccessful TPL collection attempt to qualify for payment consideration.

    Additional information

    PrimeWest Health follows the guidelines for Appeals found in the Minnesota Administrative Uniformity Committee (AUC) Companion Guides.

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    Updated_01/11/2022