Billing a PrimeWest Health Member

    Billing the PrimeWest Health Member

    PrimeWest Health allows a limited number of instances when you can bill a member for services you provided. These limited instances include (additional details below):

    1. Non-covered services (only if you inform the member in writing before you deliver the services that they would be responsible for payment) Providers may use the DHS forms listed below to notify members of non-covered services. Providers should complete the form according to the instructions and include the member’s signature on the form.
      1. Advance Recipient Notice of Non-Covered Service/Item (DHS-3640)
      2. Advance Recipient Notice of Non-Covered Prescription (DHS-3641)   
    2. Retroactive eligibility
    3. EW waiver obligations
    4. Copays

    Federally funded Medical Assistance (Medicaid) members are protected from denial of service based on inability to pay as long as they inform the provider that they are unable to pay the copay. Providers must continue to accept their assertion of inability to pay.

     

    Other State-funded Medical Assistance (Medicaid) programs are not affected by the Federal statute.

    Prohibition Against Seeking Payment from Member

    You must not request or accept payments from PrimeWest Health members, their families, or from others on behalf of the member for any of the following:

    1. Base rate changes made by PrimeWest Health
    2. Missed appointments
    3. The difference between insurance payments and U&C charges
    4. Services otherwise covered by PrimeWest Health, unless a copay or cap applies

      Non-Covered Services

      You may bill a member for non-covered services only when PrimeWest Health never covers the services, and only if you inform the member before you deliver the services that they would be responsible for payment. Providers should use a written notification form that includes the service in question, the current date and DOS (if different), cost of the services, any other pertinent information, and the member’s signature attesting that they understand that they may be billed. If PrimeWest Health normally covers a service, but the member does not meet coverage criteria at the time of the service, the provider cannot charge the member and cannot accept payment from the member.

      You should have office procedures in place to prevent misunderstandings about whether or not you properly informed a member about a non-covered service and the cost of the health service.

      You may bill a member for a service only when the following conditions apply:

      1. A service is considered not covered if:
        1. It is never covered by PrimeWest Health; or
        2. PrimeWest Health does not cover the service under the member’s major program benefit or the member does not meet PrimeWest Health criteria for the service; or
        3. It is being provided by a provider that is out of network and a single case agreement has not been established
      2. You reviewed with the following with the member:
        1. Service limits
        2. Reason(s) the service, item, or prescription is not covered
        3. Available covered alternatives
      3. You inform the member before you deliver the services that the member is responsible for payment
      4. You obtain a member signature on the appropriate form (listed below)
      5. You or an authorized health care representative completes the appropriate forms below and the provider fields and signs the forms:
        1. Advance Recipient Notice of Noncovered Service/Item (DHS-3640)
        2. Advance Member Notice of Noncovered Prescription (DHS-3641)

      Additional conditions non-pharmacy providers must meet 

      1. Non-pharmacy providers must request authorization and seek payment from the other insurance or Medicare before requesting authorization or payment from PrimeWest Health or the member.
      2. When a service or item requires authorization, non-pharmacy providers must request authorization through the PrimeWest Health medical review agent (see pharmacy conditions below). If the authorization is denied for other than a billing error or lack of documentation, you may bill the member.
      3. Non-pharmacy providers may not request payment from the member for the following:
        1. A service that requires authorization unless authorization was denied as not medically necessary and you have reviewed all other therapeutic alternatives with the member
        2. A service PrimeWest Health denied for reasons related to billing requirements
        3. Standard shipping or delivery and setup of medical equipment or medical supplies
        4. Services included in the member’s long-term care per diem
        5. More than your usual and customary charge for the service or item
        6. The difference between what PrimeWest Health would pay for a less costly alternative service and the upgraded service provided
        7. A service when the member is enrolled in the Restricted Recipient Program and the provider is one of the provider types designated for the member’s health care services
      4. If PrimeWest Health makes any payment, non-pharmacy providers may bill the member only for amounts designated as cost-sharing or spenddown

      Additional conditions pharmacies must meet 

      1. Pharmacies may not accept payment from a member, or from someone paying on behalf of the member, for any PrimeWest Health-covered prescription
      2. Pharmacies may not request payment from the member when the member is enrolled in the Restricted Recipient Program and the provider is one of a provider type designated for the member’s health care services

      Billing a member for a non-covered prescription

      The following conditions apply to a member paying for a prescription:

      1. A member may pay for a non-covered prescription for a drug (other than a controlled substance or gabapentin) if the pharmacy and member have completed an Advance Member Notice of Noncovered Prescription (DHS-3641) and all criteria have been met.
      2. A member may pay for a non-covered prescription for a controlled substance or gabapentin after the pharmacy and member have completed an Advance Member Notice of Noncovered Prescription (DHS-3641) and the form has been signed by the physician certifying that all criteria have been met.

      PW_03-19_112
      Updated_02/23/2023