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
Public Health Clinic
Public health clinics must be a department of, or operate under the direct authority of, a unit of government. Examples of a unit of government include county and city.
Covered Services
- Physician services
- Preventive health services
- Family planning services
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, also known as Child and Teen Checkups (C&TCs)
- Dental services
- Prenatal care services
- Tuberculosis (TB) case management and directly observed therapy
- Community Health Worker (CHW) patient education services (diagnosis-related) provided by a CHW under the supervision of a certified Public Health nurse
Eligible Providers
- Physician
- Physician assistant (PA)
- Advanced Practice Registered Nurse (APRN)
- Nurse practitioner (NP)
- Clinical Nurse Specialist (CNS)
- Certified Nurse Midwife (CNM)
For physician extenders, see specific supervision and reporting requirements in the Education and Counseling section of Physician and Professional Services.
Tuberculosis (TB) Case Management and Directly Observed Therapy
The Minnesota Department of Human Services (DHS) Omnibus Bill provides for coverage of case management and directly observed therapy services for PrimeWest Health members infected with TB. These services must be provided by certain people employed by a community health board.
Covered Services
Case management services include the following, at a minimum:
- Assessing the need for medical services to treat TB
- Developing a plan of care addressing those needs
- Assisting in accessing medical services identified in the care plan
- Monitoring compliance with the care plan to ensure completion of TB therapy
- Directly observed therapy
Eligible Providers
Case management services are covered if provided by a certified Public Health nurse (PHN) employed by a community health board.
Directly observed therapy must be provided by a PHN employed by a community health board or by a community outreach worker, licensed practical nurse (LPN), or registered nurse (RN) trained and supervised by a PHN employed by a community health board.
Drugs for TB
PrimeWest Health covers drugs for TB and other communicable diseases if prescribed by a licensed practitioner and dispensed by a physician or certified nurse practitioner (CNP) employed by, or under contract with, a community health board for purposes of communicable disease control.
Billing Requirements
Use code T1016 for case management and code H0033 for directly observed therapy. These two codes should not be billed on the same day, nor should office or home visits be billed on the same day as case management. Submit claims electronically using the 837P format.
Public Health Nursing Clinic (PHNC)
Public Health Nursing Clinics (PHNCs) must meet the following requirements:
- Be a department of, or operate under the direct authority of, a unit of government. Examples of a unit of government include county, city, or school district.
- Be performed at a main clinic site, satellite clinics, mobile clinic sites that are open to the public, or the member’s home
Eligible Providers
- PHNs
- Licensed Registered Nurses (RNs), supervised by a PHN, practicing in a PHNC
Covered Services
- Clinic Visits – Clinic visits may include, but are not limited to, services in the following areas:
- Health Promotion and Counseling: Education and counseling to alleviate or prevent health problems. This service does not include in-depth nutritional counseling normally performed by a licensed dietician, nor does it include structured diabetic education programs. Refer to the Medical Nutrition Therapy (MNT) and Diabetic Self-Management Training (DSMT) Services sections of Physician and Professional Services, for coverage information and requirements.
- Medication Management: Review of current medications and adherence to the prescribed medication regime. Education on proper medication use and contact with the prescribing physician when necessary.
- Nursing Assessment Treatment and Diagnostic Testing: A health history or examination that includes an evaluation of health behaviors and risk factors and is performed within the scope of practice of a licensed RN.
- CHW patient education services (diagnosis-related) provided by a CHW under the supervision of a certified Public Health nurse.
- Home Visits – PHNC services that are typically provided in the clinic setting may also be performed in the member’s home on an intermittent basis when necessary to ensure that the member receives the necessary care.
PHNC visits may not be used as a substitute for traditional home care, such as the type of home care that is reimbursable by Medicare. If a member needs traditional home care, the member should be referred to a Medicare-Certified Home Care Agency.
Non-Covered Services
- Services covered by a primary insurance
- Services that are part of the Women, Infants, and Children (WIC) food program clinic package, such as height, weight, blood pressure, and client history
Billing for Public Health Nursing Clinic (PHNC) Services
Submit claims electronically using the 837P format. Please refer to Claims & Payment for additional information.
| New Code | Description | Qualifying Information |
| T1015 | Clinic visit/encounter, all-inclusive | One unit includes all clinic services, previously reported with codes X5546 through X5549, provided to a member in one day without regard to time. C&TC services may not be billed on the same day as a PHNC clinic visit. The administration of injections is included in the clinic visit. Bill HCPCS code for drug. |
| S9445 | Patient education, non-physician provider, individual | Patient education only, non-physician provider, individual or group. May be reported on the same day as T1015. Bill one unit per person for each class session. A session is one encounter; a class that meets four weeks has four sessions/encounters. |
| S9446 | Patient education, non-physician provider, group, per session | For group education and counseling; may be reported on the same day as T1015. Bill one unit per person for each class session. A session is one encounter; a class that meets four weeks has four sessions/encounters. |
| S9123 | Nursing care, in the home, by PHN or RN This code should be used by a non-Medicare-certified PHNC only. Medicare-certified PHNC, refer to Claims & Payment | Although the S9123 code description indicates a per-hour service, PrimeWest Health reimbursement is limited to a per-visit rate. One unit equals one visit. Use the U8 modifier for billing evidence-based home visits. C&TC services may not be billed on the same day as a PHNC home visit. The administration of injections is included in the home visit. Bill HCPCS code for drug. |
| 99501 | Home visit for postnatal assessment and follow up care – mother |
|
| 99502 | Home visit for newborn care and assessment |
|
| S9443 | Lactation classes, non-physician provider, per session | Bill one unit per person for each class session. |
| H1002 | At-risk care coordination | |
| H1003 | At-risk prenatal education | |
| H1004 | At-risk enhanced service | |
| T1002 HD | Prenatal Assessment | County Public Health agency billable service |
PW_11-18_473
Updated_12/04/2024
