Physician and Professional Services

Fee-for-Time Compensation Arrangements

PrimeWest Health recognizes that physicians often retain a substitute physician to take over their professional practices while they are absent for reasons such as illness, vacations, continuing medical education, military service, pregnancy, etc. PrimeWest Health further recognizes fee-for-time compensation arrangements and pays the regular physician for the services provided by the substitute physician if any of the following criteria are true:

1. The substitute physician generally does not maintain a practice and travels from area to area as needed
2. The regular physician is unavailable to provide services
3. The member has arranged or seeks to receive the services from the regular physician
4. The regular physician pays the fee-for-time compensation physician on a per diem or a fee-for-service basis. Compensation paid by a medical group is considered paid by the physician.
5. The substitute physician does not provide services over a continuous period of longer than 60 days unless the arrangement resulted from the regular physician being called or ordered to active duty as a member of a reserve component of the Armed Forces.

Covered Services

PrimeWest Health covers fee-for-time compensation physician services using Medicare guidelines. Locum tenens services provided by an Advanced Practice Registered Nurse (APRN) are covered. Current licensure is required.

Documentation

The regular physician must keep a record of each service provided by the substitute physician along with the substitute physician’s National Provider Identifier (NPI). 

Billing

1. The member’s regular physician bills and receives payment for locum tenens physician covered services.
2. The locum tenens physician does not have to be identified on the claim.
3. Bill with modifier Q6.
4. Postoperative services performed by the locum tenens physician during the global surgery period do not require a Q6 modifier (if the services are only in connection with the surgery).

Reciprocal Billing

Reciprocal Billing Arrangements: A member’s regular physician may submit a claim for a covered service that the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if:

1. The regular physician is unavailable to provide the visit services
2. The member has arranged or seeks to receive services from the regular physician
3. The substitute does not provide services over a continuous period of longer than 60 days unless the arrangement resulted from the regular physician being called or ordered to active duty as a member of a reserve component of the Armed Forces.

These requirements do not apply to the substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. On claims submitted by the group, the group physician who actually performed the services must be identified as the rendering physician.

Billing

1. The regular physician bills and receives payment for substitute physician covered services.
2. The substitute physician does not have to be identified on the claim nor enrolled with the Minnesota Department of Human Services (DHS).
3. Bill with modifier Q5

Postoperative services performed by the substitute physician during the global surgery period do not require a Q5 modifier (if the services are in connection with the surgery).

Relocation Service Coordination (RSC)

Eligible Providers

The county of financial responsibility must assign a county case manager to visit the person within 20 working days of receiving the referral. If it is not practical for the county of financial responsibility to provide RSC, the county may coordinate with a different county or sub-contract with another vendor to provide the service.

Eligible Members

Medical Assistance (Medicaid) members residing in an eligible institution who choose to receive services and then choose to relocate to a community setting and have not exhausted targeted case management (TCM) benefits are eligible for RSC-TCM.
Members receiving RSC-TCM must meet the following criteria:

• Be age 21 or under; or
• Be age 65 or over; and
• Be on Medical Assistance (Medicaid)

Verify eligibility prior to providing services online through the PrimeWest Health provider web portal or Minnesota Information Transfer System (MN-ITS) or by calling the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

If a member is currently enrolled in PrimeWest Senior Health Complete or Minnesota Disability Health Option (MnDHO), the RSC provider must contact the health plan and arrange for that plan to provide relocation assistance.

If a member is enrolled in a contracted managed care plan other than PrimeWest Senior Health Complete or MnDHO, the RSC provided must take the necessary steps to make sure that all relocation efforts are coordinated with the appropriate health plan to ensure continuity of care and non-duplication of effort.

Covered Services

1. Development, implementation, and review of an individual relocation plan.
2. Communication with all parties necessary for the implementation of the plan.
3. Coordination of referrals to ensure access to medical, social, and other related services and supports.
4. Coordination and monitoring of the implementation of the plan and service delivery.
5. Coordination with the institution discharge planner.
6. Completion and maintenance of required documentation.
7. Travel and documentation necessary to develop and implement the plan.

Non-Covered Services

The following list of non-covered services is not all-inclusive:

1. Transition assistance when a member moves from one institution to another. For example, if a nursing facility (NF) closes, a provider cannot bill for activities related to finding another NF for the member, unless the member’s relocation plan indicates that a move to another institution is a necessary step toward the eventual community integration of that member.
2. Services provided to members on home and community based waivers.
3. Administrative functions:
   1. Intake for Medical Assistance (Medicaid) and other MHCP programs
   2. Eligibility determinations and re-determinations for Medical Assistance (Medicaid) or an Medical Assistance (Medicaid)-funded benefit such as Adult Rehabilitative Mental Health Services (ARHMS), waivered services, Vulnerable Adults and Adults with Developmental Disabilities Targeted Case Management (VA/DD–TCM)
   3. Prior authorization of services
   4. Long-Term Care Consultation (LTCC) or Developmental Disabilities (DD) screening
   5. Appeals or conciliation activities
   6. Direct services such as treatment, therapy, and other habilitative or rehabilitative services provided to the member
4. Other non-billable activities:
   1. Outreach services and marketing activities
   2. Information and referral activities prior to eligibility determinations
   3. Services without proper documentation in the member’s service plan
   4. Services to members ineligible for Medical Assistance (Medicaid)
   5. Services covered by another billing source such as private insurance or other third-party payers
   6. The time and services of the institution’s discharge planner
   7. Case management activities covered as a part of another covered service such as development of a treatment plan for home care or physical therapy services
   8. Services prior to the county of financial responsibility authorization

Limitations

Members living in the community or an ineligible institution such as an Intensive Residential Treatment Services (IRTS) that is not licensed as a hospital or NF cannot receive Relocation Service Coordination Targeted Case Management (RSC–TCM).

The RSC–TCM benefit is available during the last 180 consecutive days of a continuous institutional placement following the date on the first paid claim for RSC–TCM, Mental Health Targeted Case Management (MH–TCM), or VA/DD–TCM, regardless of the length of that placement.

RSC–TCM benefits end once a member is discharged from an eligible institution.

RSC–TCM is available for each and every institutional placement episode. If a person is discharged from an institution with or without RSC–TCM services, remains in a community living arrangement for a full day, and then returns to an institution, he/she may receive RSC–TCM services to assist with relocation. PrimeWest Health must have a record of community placement that lasts for at least one day.

Members cannot receive RSC–TCM and another type of targeted case management (MH, VA/DD, Child Welfare [CW]) during the same month while they reside in an institution. Do not bill for another type of targeted case management during the month(s) RSC–TCM is provided.

PrimeWest Senior Health Complete or MnDHO members should contact PrimeWest Health at 1-866-431-0801 (toll free) to request relocation assistance. The RSC–TCM provider must coordinate with PrimeWest Health to ensure continuity of care and non-duplication of effort.

Waiver Transitional Services

A service provider may simultaneously provide waiver transitional services and RSC–TCM. Waiver transitional services reimburse items, expenses, and related supports necessary and reasonable for the member to transition to their permanent place of residence in the community from the institution and do not duplicate these services. Payment for these services may not duplicate payments made or services provided under other programs authorized for the same purpose.

Billing

To bill RSC, PrimeWest Health requires:

1. An approved screening document within the past 12 months. An LTCC Screening Document must be face-to-face.
2. That RSC be listed as a current service on an approved screening document that covers the date of service of an RSC claim and is within one year of the claim service date.
3. The member to be in a facility living arrangement (DHS codes 41, 42, 43, 44, 45, 46, 47, 48, and 50) or a community living arrangement (DHS code 80, to be used with RSC only for an inpatient hospital stay of less than 30 days). If a person is receiving RSC while in an inpatient hospital and the living arrangement is (DHS code 80) (community), the POS on the claim must be 21 (inpatient hospital).

If the person receives RSC-TCM, they are limited to 180 consecutive days of RSC-TCM per eligible institutional admission, starting on the date they first receive any of the following services:

• RSC-TCM
• MH-TCM
• VA/DD-TCM

Providers will not be able to authorize additional days beyond the 180-day limit unless the member:

• Receives RSC
• Is discharged, and
• Is re-admitted at a later date

Bill electronically using the 837P claim format. Submit claims throughout the relocation process using the following information:

1. Use procedure code T1017 – Case management, each 15 minutes
2. Limit of 32 units (eight hours) per day
3. Bill each date of service separately, do not bill as a date span
4. Bill using the 837P format with your NPI or Unique Minnesota Provider Identifier (UMPI)

Certified private agencies, independent providers, and county/tribe contracted providers must work closely with county case managers to avoid claim denials due to ended eligibility or exceeded service limits.

You are not required to wait for discharge to occur before billing. You may submit a claim regardless of whether the community reintegration takes place through a home and community based waiver, by other means, or not at all.

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Updated_12/16/2025