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
Billing
Use ADA CDT codes when billing PrimeWest Health. New codes may not have an established rate for approximately six months or until there is a volume of claims submitted per code to determine the allowable rate. These services will be manually priced until a rate is established.
General Billing Guidelines
- Report accurate and complete information on all electronic claims
- Enter the valid tooth surface, tooth number, or oral cavity indicator when applicable
- Use your valid National Provider Identifier (NPI) as the billing provider
- Use 837D to submit claims
- Use ADA CDT codes for professional dental services
- Use 837P when billing Current Procedural Terminology (CPT) procedure codes for medical/technical services
- A principal diagnosis (ICD-10-CM code) is required when using CPT codes
- Outpatient facilities must use CPT or CDT codes on the 837I
- Report each service on a separate service line
- Report dental codes that require tooth numbers or oral cavity designations with supporting clinical documentation including tooth numbers or oral cavity designations for the service(s) provided
- Fax the Claims Attachment Cover Sheet for Health Care Claim Attachments with supporting documentation (Minnesota AUC Companion Guides)
Authorizations submitted for PrimeWest Health payments must exactly match the approved authorization. This includes all procedure codes, units, and the billing provider’s NPI.
All professional and institutional claims must be submitted electronically in order to comply with MN Stat. sec. 62J.536. These include all claims currently processed by PrimeWest Health, including 837P (professional), 837I (institutional), 837D (dental), pharmacy claims, and crossover claims, which include payment information from other insurance carriers via the coordination of benefits (COB) process.
For information on claim submission, refer to Billing Requirements.
State-Operated Dental Clinic Billing and Service Authorization Guidelines
All State-owned and operated dental clinics must submit dental claims and dental Service Authorizations to Minnesota Health Care Programs (MHCP). Dental claim processing or Service Authorization processing or determination questions should be directed to MHCP. Any dental claims that are submitted to PrimeWest Health will be rejected. Service Authorization requests submitted to PrimeWest Health will not be processed or forwarded; instead, they will be returned to the clinic. Dental services provided by State-owned clinic locations should follow the MHCP dental benefit set. For more information, contact the MHCP Provider Contact Center at 1-651-431-2700 or 1-800-366-5411.
Federally Qualified Health Center (FQHC) Billing and Service Authorization Guidelines
FQHC dental clinics are required to submit dental claims and dental Service Authorizations to Minnesota Health Care Programs (MHCP). Dental claim processing or Service Authorization processing or determination questions should be directed to MHCP. Any dental claims that are submitted to PrimeWest Health will be rejected. Service Authorization requests submitted to PrimeWest Health, will not be processed or forwarded; instead, they will be returned to the clinic. Dental services provided at FQHC dental clinics should follow the MHCP dental benefit set. For more information, contact the MHCP Provider Contact Center at 1-651-431-2700 or 1-800-366-5411.
The following are FQHC carve out exclusions:
- Medicare claims follow standard billing practice. PrimeWest Health handles final resolution.
- PrimeWest Health will continue to pay claims for MinnesotaCare members
Additional details from MHCP regarding this carve out can be found on the Department of Human Services (DHS) Federally Qualified Health Center and Rural Health Clinics web page.
Copay Guidelines
Providers are responsible for collecting copays from PrimeWest Health members. Refer to PrimeWest Health’s Copay Guidelines to determine copay amounts, members affected, and services requiring copays.
Interpreter Services
Effective January 1, 2023, dental services providers may bill for spoken and sign language interpreter services using the 837D claim format. Dental services providers bill one unit per visit utilizing CDT code D9990. 1 unit equals 15 minutes, with a maximum of 8 units. This is a covered benefit for children, pregnant women, and non-pregnant adults.
PW_11-18_441
Updated_02/05/2026
