Medicare Third Party Liability (TPL)

Medicare

Medicare is the Federal health insurance program for people age 65 or over, and certain people with disabilities. It is administered by CMS.

Medicare is primary to PrimeWest Health with the exception of the Medicare Advantage Special Needs Plans (SNP) offered by PrimeWest Health under the groups PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) (the State’s names for these programs are Minnesota Senior Health Options [MSHO] and Special Needs BasicCare [SNBC], respectively). For all Medicare Advantage SNP enrollees, claims are submitted to PrimeWest Health as the payer for their Medicare and Medicaid on one claim.

For members not enrolled in a PrimeWest Health Medicare Advantage Special Needs Plan, services that are covered by Medicare must be provided by a Medicare-enrolled provider and billed to Medicare first. Any balance remaining after Medicare payment must be billed to other liable third party payers with PrimeWest Health being the payer of last resort.

If Medicare pays a claim and the claim fails to automatically cross over from Medicare, providers must bill PrimeWest Health in exactly the same way Medicare was billed and include the COB information on the EDI claim or submit it as an attachment following the guidelines above under Claim Attachment Instructions.

If Medicare denies a claim, bill PrimeWest Health using PrimeWest Health guidelines. Include the COB information on the EDI claim or submit it as an attachment following the guidelines above under Claim Attachment Instructions.

For members that are enrolled in the PrimeWest Senior Health Complete or Prime Health Complete programs where PrimeWest Health is the payer for their Medicare and Medicaid, you will only need to submit a claim to PrimeWest Health for payment with the exception that if a member has a policy primary to Medicare, you would need to bill that insurer as primary and then bill PrimeWest Health.

When billing for Medicare-covered services, follow CMS guidelines. If the member does not have a policy primary to Medicare, but does have a supplemental Medicare plan, you do not need to bill the supplemental insurer. PrimeWest Health will process and pay the claim as both Medicare and Medicaid and seek reimbursement, if applicable, from the supplemental insurer after the claim has been processed and paid to the billing provider.

The Medicare Revenue Enhancement Program (MREP) is responsible for the development of Medicare maximization in all areas where PrimeWest Health is the payer of last resort. Medicare maximization requires providers to bill Medicare prior to billing PrimeWest Health if the member has Medicare benefits but is not a Medicare Advantage SNP enrollee. Be sure to indicate when the member is not covered by Medicare.

Third Party Liability (TPL)

PrimeWest Health members may have other health coverage. If a member does not inform you of other health coverage, obtain the information by calling 1-866-431-0802 (toll free) or by using MN–ITS or PrimeWest Health’s web portal.

Bill liable third party payers (including Veterans Benefits, private accident insurance, health maintenance organization [HMO] coverage, and other health care coverage held by or on behalf of a PrimeWest Health member) and receive payment to the fullest extent possible before billing PrimeWest Health. A member with more than one level of private benefits must receive care at the highest level available. PrimeWest Health is the payer of last resort except when the TPL is tribal insurance.

PrimeWest Health will not pay for services that could have been covered by the private payer if the applicable rules of that private plan had been followed.

Subrogation

When PrimeWest Health receives notice that a member has other insurance after a provider has billed and received payment from PrimeWest Health, PrimeWest Health has the right to subrogate the payment by billing the private accident or health care coverage and be reimbursed for PrimeWest Health funds that were paid on behalf of a member for medical services to an enrolled PrimeWest Health provider.

After the private accident or health care coverage reimburses PrimeWest Health, the payment responsibility is satisfied. Providers must accept the amount paid by PrimeWest Health as payment in full and must not bill the other health insurer or member for any additional payment. This includes attempting to replace or void claims with PrimeWest Health and then bill the other insurance.

The amount of the PrimeWest Health payment substitutes for the TPL payment amount, even if the TPL payment would have been higher.

Providers may not bill PrimeWest Health earlier than 100 days after the initial attempt if the unsuccessful billing attempt is for a member with TPL coverage derived from a parent whose obligation to pay child support is being enforced by DHS.

Unsuccessful/Member Uncooperative with Third Party Liability (TPL) Billing

Providers may only Appeal to PrimeWest Health for payment after three unsuccessful attempts have been made to collect payment from a Third Party Liability (TPL) payer, except when the TPL payer has already made payment to the recipient. The Appeal must be submitted within 90 days of the last attempt made to the TPL payer. When submitting the Appeal, include the following:

A copy or screen print of the first claim sent to the TPL payer
Documentation of two additional billing attempts
Any written communication received from the TPL payer

PrimeWest Health provider Appeal requests and supporting documentation must be submitted online through the PrimeWest Health provider web portal. Appeal decision notifications can also be viewed in the portal. If you are not registered for the web portal, please create an account.

Claims must be billed to PrimeWest Health within 180 days of the last unsuccessful TPL collection attempt to qualify for payment consideration.

Reporting Health Insurance Termination Dates

Notify PrimeWest Health of health insurance terminations and denials for persons not covered by the policy. Send a copy of the termination notice/denial or include all of the following information on office letterhead:

Member’s name
PrimeWest Health ID number
Insurance company name
Termination date
Whether the termination applies to the policy or individual
Name and phone number of the person contacted to obtain the termination information.

Mail or fax this information to:
COB Department
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Fax: 1-320-335-5323

Request for Billing Statement

Billing statements submitted to member (upon their request) must clearly state that it is not a bill, and payment has been made or could be made by PrimeWest Health. Providers must report the request in writing to PrimeWest Health.

Prohibition against Refusing to Furnish Services or Requiring Member to Bill Insurance

Providers must not refuse to furnish PrimeWest Health-covered services to a member because of a third party payer’s potential liability for payment of the service. Providers may not require PrimeWest Health members with primary insurance coverage to bill their insurance carrier. However, members must cooperate by completing and signing required forms.

PW_03-19_116
Updated_02/15/2023

Claims & Payment