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
Authorization of Services
Waiver services require approval from a case manager in the form of a completed Service Authorization. PrimeWest Health will only pay for services listed on the Service Authorization; however, an approved Service Authorization is not a guarantee of payment. For claim payment:
- Providers must continue to be actively enrolled and have the appropriate and up-to-date credentials required to provide the approved service(s)
- The member's Medical Assistance (Medicaid) and waiver eligibility must be maintained in order for the authorization to be valid
- Providers must ensure the Service Authorization is accurate upon receipt by PrimeWest Health
EW services require prior authorization from a PrimeWest Health case manager in the form of a completed Service Agreement. The Service Agreement allows the provider to bill PrimeWest Health and receive payment after services are provided. Only those services specified on the Service Agreement can be paid; however, an approved Service Agreement is not a guarantee of payment. The case manager is ultimately responsible to make sure that the Service Agreement is accurate.
The Service Agreement for EW may include the following:
- Medical Assistance (Medicaid) extended home care services or Skilled Nursing Visits (SNVs), HHA, Home Care Nursing (HCN), and PCA
- EW services consistent with the PrimeWest Health provider contract
The Service Agreement also lists the following:
- PrimeWest Health-enrolled provider who is authorized to provide the needed services
- National Provider Identifier (NPI) of the PrimeWest Health enrolled provider
- Rate of payment for the service
- Number of units approved or total amount
- Date or date span of service
- Approved procedure code(s)
- Diagnosis code to be used when billing the claim
- Medical Assistance (Medicaid) State plan home care services (SNV, HHA, HCN, and PCA) that must be utilized before EW extended services can be accessed
The EW Service Agreement displays units, duration, and rates. All authorized services must stay within the DHS published case mix budget caps and DHS published State maximum rates for services.
The information submitted on the claim must match the current service agreement or the claim will be denied.
If a member is receiving concurrent HCBS and hospice services, review the Hospice and other MA-covered services section of the DHS Provider Manual.
PW_11-19_543
Updated_01/14/2022
