Covered Services

PrimeWest Health covers room and board care for a PrimeWest Health member in a certified nursing facility or certified BCF. The care and monthly room and board services (per diem) cannot be billed until the beginning of the following month (e.g., January services cannot be billed until February 1).

Items/services usually included in the per diem (not an all-inclusive list):

1. Nursing services
2. Laundry and linen services
3. Dietary services
4. Personal hygiene items necessary for daily personal care (e.g., soap, shampoo, toothpaste, toothbrush, shaving cream, etc.)
5. Over-the-counter (OTC) drugs or supplies used on an occasional, as needed basis (e.g., aspirin, acetaminophen, antacids, cough syrups, etc.)

180-Day Benefit

PrimeWest Health is responsible for a total of 180 days of nursing home room and board for PrimeWest Senior Health Complete members. After the initial 180 days, billing for nursing home care should be submitted to DHS.

If a PrimeWest Health member is residing in a nursing home at the time he/she enrolls in PrimeWest Senior Health Complete, he/she is not entitled to the 180-day benefit. Continue to submit claims for room and board to DHS.

If a PrimeWest Health member is in the middle of his/her 180-day benefit and enrolls in PrimeWest Senior Health Complete, this benefit ends. DHS is responsible for the member’s nursing care.

Respite days do not count toward the benefit.

180-Day Separation Period

The member must reside in the community for 180 days after discharge from the SNF in order for the member to be eligible for a new 180-day benefit.

After the member is in the community for 180 days, PrimeWest Health would be responsible for a new, distinct 180-day SNF benefit period for a member who is still community based.

If the member becomes institutionalized prior to the end of the separation period, no new SNF benefit period applies.

100 Medicare Days

PrimeWest Senior Health Complete and Prime Health Complete members are entitled to up to 100 days of Medicare coverage if the Medicare qualifications have been met.

PrimeWest Health waives the three-day qualifying hospital stay for members in PrimeWest Senior Health Complete or Prime Health Complete.

The nursing facility should notify PrimeWest Health when the resident enters a Medicare skilled level of care using the skilled nursing facility (SNF) notification form on PrimeWest Health's provider web portal. Effective January 1, 2018, the SNF notification form must be submitted electronically through the web portal. Paper copies of the SNF notification form will not be accepted.

Once the 100 days of Medicare coverage are used, the person is not entitled to another 100 days, unless there has been a 60-day break from the Medicare skilled level of care.

Claims for the Medicare days for PrimeWest Senior Health Complete and Prime Health Complete members are sent to PrimeWest Health.

A member is entitled to the 100 Medicare days no matter how long he/she has been a resident at the nursing facility, as long as he/she meets the requirements of a skilled level of care.

PrimeWest Health follows Medicare skilled coverage criteria.

The Centers for Medicare & Medicaid Services (CMS) provides a list for consolidated billing items and services included in the per diem.

Ensure Medicare denials are issued in a timely manner.

Skilled nursing services are covered when necessary to maintain a member’s current condition or prevent or slow further deterioration so long as the member requires skilled care for the services to be safely and effectively provided.

Skilled therapy services are covered when an individualized assessment of a member’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the member’s current condition or to prevent or slow further deterioration is covered so long as the member requires skilled care for the safe and effective performance of the program.

Skilled Nursing Facility (SNF) Notification Form for Prime Health Complete and PrimeWest Senior Health Complete

This form is used for Prime Health Complete and PrimeWest Senior Health Complete members. This form should be used to notify PrimeWest Health of Medicare days used and notification of the 100- and 180-day benefit. This form must be submitted through the provider web portal. The reason for the skilled coverage should be included in the note section.

Items/services not included in the per diem (not an all-inclusive list):

PrimeWest Health covers the majority of costs incurred while in a nursing facility. However, residents may be responsible for some non-covered Medical Assistance (Medicaid) services, such as the following:

1. Special services
2. Other services not covered by Medical Assistance (Medicaid)
3. Spenddown amounts

Most items and medications provided to a member in an SNF are included in the per diem rate and cannot be billed separately to PrimeWest Health or the member. Refer to the Minnesota Department of Human Services (DHS) Medical Supply Coverage Guide for items and supplies that may or may not be included in the LTC per diem rate. Please review the Centers for Medicare & Medicaid Services SNF Consolidated Billing web page for more information on the services, supplies, and medications that may be billed separately. 

Additional Charges for Special Services

State law allows a facility to charge residents for special services that are not included in the per diem. Special services must be available to all residents in all areas of the facility and charged separately at the same rate for the same services. In order to qualify as a special service, the following conditions must be satisfied for Medical Assistance (Medicaid) and private-pay residents:

1. The facility must provide a detailed explanation of what is included in the case-mix rate
2. The facility must provide a detailed explanation of the special service and the additional charge
3. The cost of the special service must not have been included in the facility’s historical cost in the cost report for the prior reporting year
4. The service cannot be a licensure or certification requirement
5. Each resident or potential admission must be free to choose whether or not he/she desires to purchase the special service from the facility
6. The facility must allocate and report the cost and charges associated with the provision of special services under unallowable costs in the facility’s annual cost report (for those required to file)

Questions regarding nursing facility services may be directed to the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

Rehabilitative Services

LTCFs may provide rehabilitative services to their residents and members of the community, utilizing either their own staff or by contracting with an outside service vendor (rehab agency). Services must be provided on the premises.

The billing party may only bill physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) if it is not a part of the facility’s per diem. PrimeWest Health will not make separate reimbursement for therapy services for residents of an LTCF that includes therapy as part of the per diem rate. The party designated to do the billing shall bill for all rehabilitative services.

Leave Days (Skilled Nursing Facility [SNF]/Nursing Facility/Boarding Care Home [BCH])

Leave days are eligible for MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete payment. A leave day must be for hospital leave or therapeutic leave of a member who has not been discharged from an LTCF. A reserved bed must be held for a member on hospital leave or therapeutic leave. Payment for leave days in an SNF or nursing facility is limited to 30 percent of the applicable payment rate.

To be eligible for MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete payment, the following criteria must apply:

Hospital Leaves

1. The member must have been transferred from an LTCF to the hospital
2. The member’s record must document the date the member was transferred to the hospital and the date the member returned to the LTCF
3. The hospital leave days must be reported on the claim submitted by the LTCF with the appropriate hospital leave revenue code

Therapeutic Leaves

1. The member’s record must document the date and time the member leaves the LTCF and the date and time of return
2. The member may go on a home visit or vacation, to a camp that meets MDH licensure requirements, or to another residential setting except another LTCF, hospital, or other entity eligible to receive Federal, State, or county funds for his/her maintenance
3. The therapeutic leave days must be reported on the claim submitted by the LTCF with the appropriate therapeutic leave revenue code

Leave Day Limitations

Payment for hospital leave days is limited to 18 consecutive days for each separate and distinct episode of medically necessary hospitalization. Separate and distinct episode means:

1. The occurrence of a health condition that is an emergency
2. The occurrence of a health condition that requires inpatient hospital services, but is not related to a condition that required previous hospitalization and was not evident at the time of discharge
3. The repeat occurrence of a health condition that is not an emergency, but requires inpatient hospitalization at least two calendar days after the member’s most recent discharge from the hospital

MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete payment for therapeutic leave days is limited to the number of days listed below:

1. Members in an SNF, nursing facility, or certified BCF are entitled to 36 leave days per calendar year.
2. MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete payment for leave days beyond the 18- or 36-day limit is prohibited, regardless of the occupancy rate. However, the resident or family may opt to pay the LTCF to hold the bed beyond the MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete benefit period, if the facility offers this special service. If a resident is on leave day status, under most circumstances the facility may not discharge the resident or fill the bed with another resident until after the 18- or 36-day leave period has elapsed, and not at all if the resident has elected to self-pay for days beyond the 18- or 36-day leave period. This policy applies regardless of the facility’s occupancy rate. MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete residents who exhaust their hospital leave days and are subsequently discharged from the facility are entitled to be readmitted to the facility to the next available bed.

Note: A 30-day notice may be required before a resident can be discharged due to leave days being exhausted, as provided in MN Stat. sec. 144.652, subd. 29.

Determining the Number of Leave Days

According to the definition of “leave day,” an overnight absence of more than 23 hours is considered a leave day that must be reported. An absence of less than 23 hours on the first day is not a leave day. After the first 23 hours, each time the clock passes midnight counts as an additional leave day. Examples:

Occupancy Rate

Payment for hospital leave and therapeutic leave days are subject to the following occupancy rates:

1. LTCFs with 25 or more licensed beds will not receive payment if the average occupancy rate was less than 96 percent during the month of leave
2. LTCFs with 24 or fewer licensed beds will not receive payment if a licensed bed has been vacant for 60 consecutive days prior to the first leave day (date of death or discharge will be considered day one when counting consecutive days.)
3. The LTCF charge for a leave day must not exceed the charge for a leave day for a private paying resident in the same type of bed

The occupancy rate may be calculated separately for each level of care in the facility as follows:

1. Determine the number of days each licensed bed was occupied during the month. (Note: A reserved bed is to be considered an occupied bed for this purpose)
2. Total to determine the number of occupied bed days for the month
3. Divide by the number of days in the current month
4. Divide by the number of licensed beds to determine the occupancy rate for the month. For questions on SNF/nursing facility/BCH bed hold and leave day policy, call PrimeWest Health’s Provider Contact Center at 1-866-431-0802 (toll free).

Private (Single Bed) Rooms in Nursing Facilities

To receive payment from PrimeWest Health for a single bedroom for an MSC+/PrimeWest Senior Health Complete/SNBC/Prime Health Complete member, the following requirements must be met:

1. The member’s attending physician must determine and certify that a single bed room is necessary because of a medical or behavioral condition that affects the health of the member or other residents (the estimated length of time the private room is needed must also be indicated)
2. The single bed room must be located in a nursing facility that has chosen to assign a greater proportion of their costs to single bed rooms
3. The bed in the single bed room must be certified for Medical Assistance (Medicaid) by MDH
4. The facility must estimate the length of time the private room is needed
5. The Quality Assessment and Assurance Committee (QAAC) must recommend the single bed room and document the member’s condition necessitating the single bed room
6. The attending physician’s statement, the QAAC’s statement, and any additional relevant documentation from the member’s medical record, must be submitted to PrimeWest Health for review, using the Private Room Request Form
   1. Indicate the effective start date of the private room. If there is no date indicated, the signature date of the physician will be used as the start date for the authorization of the private room.
7. If member is age 65 or over, send the completed form by secure email to seniorcare@primewest.org or by fax to: 1-866-431-0804
8. If member is under age 65, send the completed form by secure email to seniorcare@primewest.org or by fax to: 1-866-431-0804
9. If member has exhausted his/her 180- or 100-day liability benefit with PrimeWest Health, use the DHS Private Room Request form and send to:
   Minnesota Department of Human Services
   Nursing Facility Rates and Policy—Private Room Request
   
   Fax: 1-651-431-7466

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Updated_10/26/2020