Claims Submission

All claims submitted to PrimeWest Health by health care providers providing services for a fee must be transmitted electronically.

Clearinghouse Options
Free Online Claims Submission Tools

Claims Address

Use the following address on medical and dental electronic claims:

PrimeWest Health 
3905 Dakota St
Alexandria, MN 56308

Claim Attachment Instructions

On your EDI claim, complete the PWK segment, Loop 2300, with a unique biller-created attachment control number. This number must be unique for each attachment submitted to PrimeWest Health in order for us to match it to the number indicated on the Claim Attachment Cover Sheet. Each claim attachment must be submitted via a unique fax submission with a unique control number and cover sheet. If you are not familiar with the PWK segment, Loop 2300, contact your billing system vendor.

If you use Office Ally for your 837P, 837I, and 837D claims submissions, the EDI attachment process is now available. Attachment fields are available in the Online Entry tool and are listed as Attachment Report Type Code, Attachment Transmission Code, and Attachment Control Number. These fields will populate the PWK01, PWK02, and PWK06 segments.

  1. Submit your EDI claim to PrimeWest Health
  2. Complete the Claim Attachment Cover Sheet, including the attachment control number. The attachment control number on the Claim Attachment Cover Sheet should match the attachment control number on the EDI claim.
  3. Fax the corresponding Claim Attachment Cover Sheet and the attachment(s) to 1-320-762-1805. You may submit the attachment information at the same time as you submit your claim(s).

PrimeWest Health will match the faxed documents to the identifiers/attachment control number submitted on the EDI claim and process accordingly. Failure to submit the faxed attachment in a timely manner (defined as three days from submission date of the claim) may result in delayed claims processing, including eventual denial of claims.

 

PrimeWest Health is following the Minnesota AUC’s “best practice” guidelines for submitting attachments. You can find the complete instructions for submitting attachments on the Minnesota AUC website.

Coordination of Benefits (COB)

Primary payer or COB information can be submitted as part of your electronic claims, eliminating the need to submit attachments. If you are submitting this information, you must include the “other payer” paid, and member and provider responsibility amounts, per the Minnesota AUC Administrative Simplification Best Practices.

When submitting claims to PrimeWest Health and PrimeWest Health is the secondary payer after Medicare, the EDI data must include the Medicare Internal Control Number (ICN). The Medicare ICN is located in the EDI data in Loop 2330B, REF segment “Other Payer Claim Control Number.”

When submitting COB claims to PrimeWest Health, the prior payer’s payment information must be included in the 837 claim file sent to PrimeWest Health to ensure that the claim balances. The only exception to this requirement is when a provider submits the claim to the secondary payer (PrimeWest Health), knowing that the primary payer does not cover the service. In these instances, the PrimeWest Health edit requires the COB non-covered amount (AMT02) to be reported, and AMT02 must equal the total claim charge amount (CLM02) included in the 837 claim file.

There are two specific balancing levels that PrimeWest Health edits for, per the ASC X12 TR3 Guide. The first balancing edit is at the claim level. It determines if the total charges at the claim level equal the prior payer’s payment amounts plus all adjustments at the claim and line level. The following is an example of claim level balancing. The data in in blue shows how the claim level must balance.

Total Claim Amount (CLM02) = sum of the Prior Payer Payment Amounts (AMT02 when AMT01="D") at the claim level (Loop 2320) plus Claim Adjustment Amounts (CAS03) at the claim level (Loop 2320) + Service Level Adjustment Amounts (CAS03) at the service level (Loop 2430).

Claim Level Balancing
CLM*1234567A6*>137***11:B:1*Y*A*Y*Y*P
AMT*D*>47.28
CAS*CO*45**>77.86
CAS*PR*2*11.86
137 = 47.28 + 77.86 + 11.86

The second balancing edit is at the line level. This edit is to verify that each charge line balances with the payment information at the line level. The following is an example of line level balancing. The data in red shows how the line level must balance.

Service Level (Loop 2400) Line Item Charge Amount Professional (SV102) or Line Item Charge Amount Institutional (SV203) = the sum of all other payer Service Line Paid Amounts (SVD02) at the service level (Loop 2430) + the sum of all the Service Line Adjustments (CAS03) at the service level (Loop 2430)

Line Level Balancing
SV1*HC:90834*137*UN*1***1:2:3
DTP*472*D8*20130513
SVD*99726*47.28*HC:90834**1
CAS*CO*45*77.86
CAS*PR*2*11.86
137 = 47.28 + 77.86 + 11.86

Claims Submission

Providers who render or supervise services are responsible for claims submitted to PrimeWest Health.

  1. Submit claims only after you provide PrimeWest Health-covered services
  2. Bill only for dates of service when services were provided except in the case of EW services for environmental accessibility adaptations (EAA) when the payments must be prorated over several months due to EW budgets and are specified on the Service Authorization.
  3. A claim cannot be submitted if a member doesn’t show up for the appointment
  4. Bill only one calendar month of service per claim
  5. Bill the provider’s usual and customary (U&C) charge
  6. All claims require a valid diagnosis (International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]) code
    1. As part of the 2011 Minnesota Legislative session, all claims for supplies or services that are based on an order or referral must include the ordering or referring provider’s National Provider Identifier (NPI) (MN Stat. sec. 256B.03, subd. 5). The ordering or referring provider must also be enrolled in MHCP. Claims submitted without this information will deny as “referring/ordering provider is not registered with MHCP.”
    2. If attending, rendering, or referring providers are present in the claim transaction, the NPI or Unique Minnesota Provider Identifier (UMPI) must be present in order for PrimeWest Health to pay the claim. If not present, the claim will be rejected back to the provider.
  7. Submit all claims electronically
    1. All claims being submitted to PrimeWest Health by health care providers providing services for a fee must be transmitted electronically. PrimeWest Health offers two methods of free online direct claims submission through a web-based program, Infotech Global, Inc. (IGI) (a.k.a. MN E-connect [Registration Information]) or Office Ally.
      1. These clearinghouses are available to submit claims electronically to PrimeWest Health
      2. Follow HIPAA EDI standards as outlined in the X12 or National Council for Prescription Drug Programs (NCPDP) Implementation Guides
      3. Follow standards outlined in the Administrative Simplification Best Practices
      4. PrimeWest Health does not have any specific file naming conventions when submitting claims
  8. PrimeWest Health follows CMS on the ordering/referring provider enrollment requirement. If the ordering/referring provider listed on claims for Medicare Part B services, Durable Medical Equipment (DME), or Part A home health agency (HHA) services is not enrolled with CMS, your claim will be denied. If this information is missing or incorrect, the following types of claims will be denied:
    1. Claims from laboratories for ordered tests
    2. Claims from imaging centers for ordered imaging procedures
    3. Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS
    4. Claims from Part A HHAs
  9. PrimeWest Health uses a claims editing system (CES) in processing claims. The CES incorporates Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) policies in claim processing. PrimeWest Health’s CES is continuously updated to remain in compliance with State and Federal regulatory mandates as well as general industry standards.

National Correct Coding Initiative in Medicaid

The CMS National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B claims and Medicaid claims. For information about, and edits for, the Medicare NCCI program, see the CMS National Correct Coding Initiative Edits web page. The Medicaid NCCI program has significant differences from the Medicare NCCI program.

The National Correct Coding Initiative (NCCI) contains the following two types of edits:

  1. NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect code combinations are reported.
  2. Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service.

Troubleshooting Resources

PrimeWest Health Clearinghouse Rejection Information

 

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Updated_12/30/2025