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
Inpatient Services
Covered Inpatient Hospital Services
Inpatient hospital services are covered if determined medically necessary. Inpatient services provided by the same hospital on two separate patient care units by two medical services are billed as one continuous admission. This includes patients transferred between acute general medical/surgical services to or from general psychiatric services.
Inpatient admission for detoxification is not covered under PrimeWest Health unless it is required for medical treatment. Inpatient hospitalization may be medically necessary due to conditions resulting from withdrawal or conditions occurring in addition to withdrawal and the conditions require constant availability of a physician and registered nurse and/or complex medical equipment found only in an inpatient hospital setting. The medical records of members admitted for detoxification are subject to retrospective review by the medical review team. Inpatient medical detoxification and/or treatment of sequelae resulting from drug or alcohol ingestion are billed as any other acute inpatient admission.
Inpatient-Only Procedures
Dually Eligible Medicare and Medicaid Members
The Centers for Medicare & Medicaid Services (CMS)-identified inpatient-only procedures provided to members who are dually eligible for Medicare and Medicaid must be provided in an inpatient setting for PrimeWest Health to pay the coinsurance and deductible amount. PrimeWest Health will not make payment if the inpatient only procedure is performed in an outpatient setting for a dually eligible Medicare/Medicaid member.
Medicaid-Only Members
PrimeWest Health identifies procedures that should be performed only in an outpatient setting. PrimeWest Health follows Medicare guidelines for payment for inpatient-only procedures and pays for these procedures only on inpatient claims.
Medicaid Members with Third Party Liability (TPL)
Providers must follow the POS rule of the primary payer. PrimeWest Health will not make payment if the POS rule of the primary payer is not followed.
Point of Origin for Admission or Visit
Completion of this field (UB-04 Form Locator 15) is required for all institutional inpatient and outpatient claims except those with TOB 014x. This code indicates the point of patient origin for the admission or visit of the claim being billed.
Example: When a patient presents to the emergency department and subsequently is admitted as an inpatient, the Point of Origin code would be 1 if the patient came from home or any other non-health care facility location.
Present on Admission (POA) Indicator
The POA indicator is now required for all inpatient claims. POA is defined as “present at the time the order for inpatient admission occurs.” Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
MN Stat 256.969, subd. 3b, indicates that the State will no longer pay for services related to a hospital-acquired condition. PrimeWest Health adopted this MHCP guideline and requires the POA indicator on all inpatient claims for all hospital provider types (acute care). We will use this indicator to identify services related to a hospital-acquired condition.
Per Minnesota Law, you are not to bill the member for any payment disallowed due to this ruling.
The POA indicator is assigned to principal and secondary diagnoses and the external cause of the injury codes. CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
Birth Weight requirement
Hospitals must include value code 54 (Newborn Birthweight in Grams) on all claims for babies under 29 days at time of admission. This is regardless of whether the baby was born inside or outside the hospital, and whether the newborn was transferred to or from the hospital. If an ICD-10 diagnosis code indicating birth weight is reported on the claim, the birth weight must correlate to the weight reported with value code 54.
Covered Days
Covered days are reported with value code 80.
Value code 80 is required to indicate covered days, which is equivalent to accommodation days. If the value code is not listed, the claim will be rejected.
PW_11-18_493
Updated_12/16/2025
