Billing

Payer Determination

All providers and local agencies are responsible to bill available payers for services. The order of payers is as follows:

1. Third party payers (e.g., large and small group health plans, private health plans, group health plans covering the member with End Stage Renal Disease [ESRD] for the first 18 months, workers’ compensation law or plan, no-fault or liability insurance policy or plan)
2. Medicare and Medicare Advantage Plans (Medicare must always be billed unless the item is a Medicare non-covered service)
3. Minnesota Health Care Programs (PrimeWest Health)
4. Waiver Programs

Elderly Waiver (EW) services must be billed using the 837P Professional claim transaction. Refer to Claims & Payment for more information. Under no circumstances may a provider initiate and bill for service delivery prior to the full execution of a contract for waiver services. Before submitting a claim to PrimeWest Health for EW services, the provider should verify that the Service Agreement is current. Providers of EW services should contact PrimeWest Health if they do not have a current service agreement.

It is recommended that providers verify the program eligibility of a member on a monthly basis.

Diagnosis Codes

PrimeWest Health requires providers to enter the most current and most specific primary diagnosis code when submitting claims for EW services

Service Authorization/Agreement letters to the provider will display the diagnosis code of the member if the diagnosis is required for billing. The diagnosis is captured from the primary diagnosis field on the last approved screening document.

Authorized Services vs. Non-Authorized Services

Services that require a Service Authorization cannot be billed on the same claim as services that do not require a Service Authorization. For example, services for Medical Assistance (Medicaid)-eligible members and home care therapy services (physical, occupational, respiratory, and speech therapy) do not require a Service Authorization and cannot be billed on the same claim form as a waiver service, such as adult day services.

PrimeWest Health requires providers to obtain Service Agreements or Service Authorization forms for EW services prior to the start of service in order to ensure prompt and accurate provider payment. There are many advantages for providers to coordinate their efforts with PrimeWest Health in order to ensure that a member receives their necessary services and providers receive timely payments for services rendered.

Payment Rates

PrimeWest Health negotiates contracts with Home and Community Based Services (HCBS) waiver providers and sets service provider reimbursement rates according to published DHS State reimbursement rates. Customized Living (CL) and 24-Hour CL provider reimbursement rates are determined through use of the Residential Services tool in the MnCHOICES Support Plan application.

Rates are a fixed charge per unit of a commodity or service.

DHS establishes upper rate limits for EW services. Service rates authorized and claimed may not exceed the DHS published maximum allowable service rates, and, for some market rate services must be determined based on the lowest cost-effective bid within the limits.

Information about service rate changes and limits for EW services are first made available through publication of Bulletins. Review the DHS Long-Term Services and Supports Rates Changes web page for the most up-to-date information about the current rate limits.

Elderly Waiver Customized Living (CL) Services Rate Adjustment

Providers of CL services may be eligible for a rate floor, or minimum daily rate adjustment, for individual members on Elderly Waiver (EW) receiving 24-hour CL services. To qualify, providers must apply to DHS to be designated as a disproportionate share facility. Only facilities satisfying all of the following conditions on September 1 of the application year are eligible for designation as a disproportionate share facility:

• at least 83.5 percent of the residents of the facility are CL residents; and
• at least 70 percent of the CL residents are enrolled in EW.

"CL resident" means a resident of a facility who is receiving either 24-hour CL services or CL services authorized under EW, the Brain Injury Waiver, or the Community Access for Disability Inclusion Waiver.

Facilities must apply annually between Sept. 1 – 30 using the Disproportionate Share Facility Application (DHS-8157). Facilities must submit one application for each licensed assisted living facility. A facility that holds a single license for a setting that meets the definition of an assisted living facility campus under MN Stat. 144G.08, subd. 4a, must submit one application for the licensed campus. Providers who are exempt from assisted living licensure must submit one application for each building that has a unique street address. As a part of reviewing completed application forms, DHS will request applicants to submit a census list of members on a waiver program in a secure and encrypted format to verify the resident numbers submitted on the application form.

DHS will designate eligible facilities by October 15, and qualified facilities receive the minimum daily rate adjustment from January 1 through December 31 in the year immediately following the application period. If an individual facility is not enrolled to provide CL services, the facility’s enrollment must be completed before the rate adjustment can take effect.

The minimum daily rate adjustment does not affect lead agency processes, provider billing processes, or individual monthly case mix budgets. Lead agencies calculate the participant’s daily rate using the Elderly Waiver Residential Services (EWRS) Rate Tool in the MnCHOICES Support Plan. Service Authorizations state the daily rate derived by the EWRS Rate Tool and do not account for the minimum daily rate. Providers submit claims for the daily rate on the service authorization. The provider receives the value of the minimum daily rate as a claims adjustment, which does not count against a participant’s monthly case mix budget.

Example: A CL provider designated as a disproportionate share facility serves an EW member with a daily rate of $89 based on the participant’s EWRS Rate Tool result. When the facility submits a claim, the payment system will see the authorized amount of $89 and adjust the claim payment up to the value of the rate floor. The facility receives the additional value of the adjustment, which does not affect the participant’s daily rate or case mix budget cap.

Individual disproportionate share facilities began receiving minimum daily rate payments in calendar year 2022, when the rate adjustment first took effect. DHS adjusts the value of the minimum daily rate annually on January 1 as directed by law. The rate floor amounts are reported in the following table:
 

For questions about the CL services rate adjustment, contact dhs.aasd.hcbs@state.mn.us.

Members Leaving Nursing Facilities (Conversion Rates)

People receiving EW services may access a higher monthly budget if the person is a resident of a certified nursing facility and has lived there for 30 consecutive days. Refer to DHS Elderly Waiver (EW) conversion rates.

EW Obligation

Eligibility for EW is based on two income limits:

1. People with incomes equal to or less than the Special Income Standard (SIS) are eligible for EW without a Medical Assistance (Medicaid) spenddown. They must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.
2. People with incomes greater than the SIS may still be eligible for EW but they may have a waiver obligation. The lead agency’s financial assistance unit is responsible for determining the financial obligation of the EW member. The member is informed if they have a waiver obligation.

The waiver obligation is deducted from the cost of services received under EW, and the full amount of the waiver obligation does not have to be met each month. The member is responsible to pay the amount of the obligation toward the services that were utilized that month. This may be a portion of the waiver obligation or the entire waiver obligation.

Claims that are reduced due to the EW obligation will show claim adjustment reason code PR 142 on the remittance advice. PrimeWest Health also receives reports on members who have waiver obligations. PrimeWest Health has a process for informing providers regarding amounts of waiver obligations.

A member can designate a provider to whom they will pay their obligation. The member must notify their financial worker if they wish to choose this option.

Home Care Services Provided for Medical Assistance (Medicaid)-Eligible Members Receiving EW Services

All member receiving EW services must first access State plan Medical Assistance (Medicaid) home care services to the highest extent before adding EW services to the community support plan.

Medical Assistance (Medicaid) covers the following home care services:

• Community First Services and Supports (CFSS)
• Home care nursing (HCN)
• Home health aide (HHA) visits
• Occupational therapy (OT)
• RN PCA supervision
• Personal care assistant (PCA)
• Physical therapy (PT)
• Respiratory therapy (RT)
• Skilled nursing visits (SNV)
• Speech therapy (ST)

Home Care and EW Waiver

1. Some members on EW receive their EW services fee-for-service (FFS) and their Medical Assistance (Medicaid) home care through managed care, formally known as the Prepaid Medical Assistance Program (PMAP).
2. The managed care products that serve PrimeWest Health EW members are Minnesota Senior Care Plus (MSC+) and PrimeWest Senior Health Complete (HMO SNP).
3. With the exception of therapy services, the FFS EW service case manager determines the amount of home care services and approves the Service Agreement. When the member has Medical Assistance (Medicaid) services through managed care, the case manager uses a pseudo code (X5609), which authorizes the amount of home care services that are counted toward the member’s case mix budget.
4. For PrimeWest Health members receiving EW services, the designated care coordinator is responsible for approval and provision of all home care and EW services.

Extended Home Care Services – EW

Extended home care services include extended PCA/CFSS, extended HHA, and extended home health nursing (RN/licensed practical nurse [LPN]).

1. A member must first access needed home care service benefits through Medical Assistance (Medicaid) home care before “extended home care” benefits may be approved.
2. Home care service needs that cannot be met within the Medical Assistance (Medicaid) home care limits may be approved and billed to EW as extended Medical Assistance (Medicaid) services within the budget limit available.

Submitting Claims

Bill only for services already provided and approved on the Service Authorization.

When submitting claims for waiver program services, do the following:

1. Enter a diagnosis code when submitting claims for all waiver services. Use the most current, most specific diagnosis code when submitting claims. The Service Authorization will display the diagnosis code that should be used on the claim.
2. Use date spans only for monthly codes when you have provided services for all dates in the span; otherwise, bill each date on a separate line.
3. Submit the rate that is included on the Service Authorization.

Billing Procedure Codes
Use the following billing guidelines to bill 15-minute procedure codes for time spent providing the service.

To bill for hourly procedure codes for time spent providing the service, a unit of time is attained when the length of time providing the service passes the hour mid-point. For example, an hour of billable time is attained when 31 minutes have elapsed. A second hour is attained when a total of 91 minutes have elapsed.

To bill for daily procedure codes, use daily or per diem codes found on your Service Authorization that do not have a timed component or unit assigned, regardless of the time spent.

To bill for monthly procedure codes, do the following:

1. Only use monthly procedure codes after the service has been provided for the month.
2. Bill for the dates on which the services were provided. If the service is a monthly service and the person was absent in the middle of the month, enter one prorated unit for each time span the services were provided. For example, if the person was hospitalized from January 15 – 25:
   1. Bill January 1 – 14 on line one of the claim
   2. Bill January 26 – 31 on line two
   3. In this case, if the entire month was billed, the claim would be denied
3. If the waiver claim is paid before the hospital or long-term care facility claim is submitted, PrimeWest Health will automatically take back the waiver payment when the hospital or long-term care facility claim is processed. The provider must then resubmit the claim.

Multiple Providers Providing the Same Service at the Same Time

More than one provider may be authorized to provide the same service for the same person.

1. Each provider must have a separate line item on the Service Authorization.
2. If the service has a daily or monthly procedure code, more than one provider cannot bill for the same service.
3. Services must be coordinated:
4. Each provider bills for the actual dates of service.
5. Use date spans on claims when services are provided on consecutive days.
6. If multiple providers will bill for the same daily or monthly procedure code over the same period, the case manager must contact all providers to coordinate services to assure there is no duplication.
7. Two facilities cannot both bill a daily code when a person moves from one facility to another on the same day. If both providers want to bill for the hours they actually provided services, the county must approve 15-minute units for that date if there is an equivalent 15-minute code for the service. If there is only a daily or per diem code, whichever location the person resides in at midnight is the location that is able to bill for that day. For example, if a person leaves agency A at 3:30 p.m. on June 1 and then moves to agency B at 3:31 p.m. on June 1, agency B bills for June 1.

Waiver Services for an Individual in an Institutional Setting

Waiver services are not covered for dates of service when a PrimeWest Health member is also receiving services in an inpatient hospital, nursing facility, or intermediate care facility for persons with developmental disabilities (ICF/DD).

Providers may bill PrimeWest Health for waiver services provided on the date of admission or the date of discharge from a hospital if they provided services before the time of admission or after the time of discharge with the appropriate 15-minute code. If the person was previously approved for a procedure code that is a per diem or daily code, the provider must contact the case manager for authorization of the 15-minute code on the Service Authorization. If there is only a per diem code, PrimeWest Health will deny the claim.

Exception: Waivers allow payment for respite care services provided in a hospital or long-term care facility using respite care procedure codes. See the DHS respite care description.

Waiver services in a residential setting

The following waiver services are covered in a residential setting:

1. Customized Living
2. Adult foster care
3. Community residential services
4. Family residential services
5. Integrated community supports

Waivers do not pay for room and board with the exception of respite and caregiver living expenses. Other income sources such as Social Security Disability Insurance (SSDI), General Assistance (GA), Supplemental Security Income (SSI), and housing support may cover room and board. See the DHS Housing Support web page for more information. The county worker determines all appropriate payment sources for room and board.

Absences from a Residential Setting for EW

The following applies to residential services provided under Elderly Waiver (EW).

Definition: Days when a person is not receiving residential services are days the person is not in the residential setting.

Providers may not bill for full days when PrimeWest Health members are absent from the residential service settings, regardless of the reason for the absence. An overnight absence of more than 23 hours is a non-covered day. An absence of less than 23 hours on the first day is covered if the day does not overlap with a long-term care facility admission date. After the first 23 hours, each time the clock passes midnight counts as another non-covered day. Providers must pro-rate billing to reflect non-covered days during the month.

Centers for Medicare & Medicaid Services (CMS) policy states Medicaid will pay for services actually provided to an eligible member. Providers may not bill for full days when MHCP members are absent from the residential setting, regardless of the reason for the absence. If an individual receives service for any portion of a day, providers may bill for that day.

See the following examples for a person on EW that leaves the residential service setting and returns at a later date:

Regardless of calculating absence, a residential service provider may not bill for dates of service that overlap with a long-term care facility admission date.

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Updated_12/22/2025