Billing Policy

Definitions

Assignment or Assignment of Benefits: The written authorization by a person, the person’s authorized representative, a policyholder, or other authorized representative to transfer to another individual, entity, or agency his/her right or the rights of his/her dependents to medical care, support, or other third party payments.

Billing Intermediary: Agent, person, or entity that submits claims or transactions and/or receives PrimeWest Health payment on behalf of one or more “pay-to” providers under one billing number (this agent can be part of the provider organization or a separate billing organization). Payment may be directed to a billing intermediary (such as an accounting firm or billing service) that furnishes statements and receives payments in the name of the provider if the agent’s compensation for these services is:

1. Related to the cost of processing the billing;
2. Not related on a percentage (or other basis) to the amount that is billed or collected; and
3. Not dependent on collection of the payment.

Clean Claim: As defined in Section 1.6 of the PrimeWest Health Provider Participation Agreement, that pursuant to Title 42 Code of Federal Regulations (CFR) 447.45, 42 CFR 447.46, and MN Stat. sec. 62Q.75, a claim that has no defect or impropriety, including any lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment from being made on the claim.

Clearinghouse: Public or private entity (including, but not limited to, billing services, re-pricing companies, community health management information systems or community health information systems, value-added networks and switching companies) that does either of the following:

1. Processes or facilitates the processing of nonstandard information or data elements into standard data elements or standard transactions
2. Receives a standard transaction from another entity and processes or facilitates the processing of this information into nonstandard format or nonstandard data content for a receiving entity

Pay-to Provider: Provider to whom PrimeWest Health payment is issued for services provided to a member.

Private Insurer:

1. Any commercial insurance company offering health or casualty insurance to individuals or groups (including both experience-rated and indemnity contracts);
2. Any profit or nonprofit prepaid plan offering either indirect services or full or partial payment for the diagnosis and treatment of an injury, disease, or disability; or
3. Any organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employers, employee benefit plans, and any similar organization offering these payments for services, including self-insured and self-funded plans.

Third Party Payer: Any individual, entity, or program that is or may be liable to pay all or part of the health care costs incurred by members, including Medicare, an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), TriCare (formerly CHAMPUS), Workers’ Compensation, and uncontested no-fault automobile insurance.

Third Party Liability (TPL): Payment resources available from both private and public health insurance and other liable third parties that can be applied toward a member’s health care expenses.

PW_03-19_126
Updated_02/19/2020