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
Non-Covered Services
The following services are considered non-covered. Separate billing, to either PrimeWest Health or the member, is prohibited for these services unless the member is informed in advance and signs an Advanced Beneficiary Notice (ABN). This is not an all-inclusive list.
- CDT codes not mentioned in the Covered Services section are non-covered services
- Barriers
- Disposable equipment/supplies
- Drapes
- Eye protection
- Fluoride trays or rinses
- Gauze/sterile packing
- Gloves
- Infection control procedures
- MinnesotaCare tax
- Needles
- Periodontal charting (separate from codes D0150 or D0180)
- Prescriptions dispensed in the office
- Prosthetic cleaning
- Sterilization solutions/equipment
- Surgical supplies
- Suture material
- Syringes
- Treatment deemed to be cosmetic or for aesthetic reasons
PW_11-18_440
Updated_11/01/2018
