Billing

PrimeWest Health Notification Process

PrimeWest Health members may be admitted to treatment without prior authorization for services. A service notification letter is generated when PrimeWest Health receives the notification through the PrimeWest Health Provider Portal. Providers must review service notification letters for accuracy and must not bill from an inaccurate service notification letter. If problems exist on the service notification letter (e.g., incorrect dates, modifiers), the provider must contact PrimeWest Health and request the necessary changes. Once the changes are made, another service notification letter will be generated. Providers must only bill PrimeWest Health when they have received an accurate service notification letter.

Effective January 1, 2024, notifications are not required for residential withdrawal management, treatment coordination services, and peer recovery support services. When billing for these services for dates of service on or after January 1, 2024, providers do not need to submit a notification to PrimeWest Health prior to billing nor must they include a notification number on these claims when billing.

Modifiers: All modifiers associated with the approved services must be included on the claim in order to be considered for reimbursement.

Discharge Date: The PrimeWest Health notification letter will not include the discharge date; however, it must be included on the claim as the service end date to follow standard billing practices. Enter the service end date as the date of discharge. Providers should submit a completed discharge summary for all PrimeWest Health members to PrimeWest Health upon member’s discharge.

PrimeWest Health Substance Use Disorder (SUD) Coding Structure

Treatment Services

Treatment services can be delivered as either individual or group services.
Any service that is billed for at a group rate, including all treatment services identified in MN Stat. 245G.07, must not exceed the counseling group staffing requirements in MN Stat. 245G.10, subd. 4. (adults) or MN Stat. 245G.16, subd. 3. (adolescents).

Treatment services, billed by hour of service delivered and specific to the procedure code used.
Providers billing for treatment services must use the appropriate Healthcare Common Procedure Coding System (HCPCS) code based on the American Medical Association's Current Procedural Terminology (CPT).

Treatment services billed in nonresidential programs.
For nonresidential (outpatient) services, codes H2035 and H2035 HQ are used for individual counseling and group treatment services, respectively. These codes are defined as “alcohol and/or drug counseling per hour” and are measured in units of time. More than half of the time must be spent providing the treatment service to an individual, excluding any breaks, to report these codes. For example, if a provider schedules 60 minutes and the member leaves after 50 minutes, the provider is still able to bill for the hour. This does not allow providers to schedule units of less than one hour. 

In addition, billable treatment units may not cover a previously billed time. For example, a provider may not bill two hours/units of service when the member attends two consecutive 31-minute group sessions with a short five-minute break in between (e.g., group from 9 – 9:31 a.m., then a break from 9:31 – 9:36 a.m., then group from 9:36 – 10:07 a.m.). In this example, the member received a total of 62 minutes of service, which is one hour/unit of service and not two hours/units of service. Scheduling in units less than one hour deprives the member of the benefit of the full unit of service.

HCPCS code H0038 U8 is used for peer recovery support and T1016 U8 HN is used for treatment coordination. These codes are defined as “peer support services, per 15 minutes,” and “case management, each 15 minutes.” Because these codes are defined by a unit of time, both the Administrative Uniformity Committee (AUC) and CPT language support the concept that the unit of time is attained when the mid-point is passed, and that more than half of the time must be spent performing the service in order to report that code, excluding any breaks. Accordingly, treatment services must last 8 continuous minutes to qualify as 15 minutes of service. Breaks may not be included in these continues minutes.

• T1016 U8 HN (Treatment Coordination) – 8 units per day (2 hours)
• H0038 U8 (Peer Recovery Support) – maximum of 16 units (4 hours) per day per individual and maximum of 56 units (14 hours) per week per individual 

Billable Units and Time Requirements

Units and measurement

Providers may not submit a claim for an individual service and group service for the same encounter. Time should be documented, counted, and billed to reflect the correct service distinct from one another (for example, individual counseling, treatment coordination, etc.).

A claim submission for service provided during the remaining balance of a unit of time is duplicative and ineligible for reimbursement. For example, billing one unit of individual counseling for a session that did not last the entire hour and then starting another different service within the remaining balance of time of that one-hour unit of individual counseling would be considered duplicative and ineligible for payment.

Follow HCPCS and CPT guidelines to determine the appropriate units of time to report as part of the code definition. Per the guidelines, providers must spend more than half the time of a time-based code performing the service to report the code. If the time spent results in more than half the defined value of the code, and no additional time increment code exists, round up to the next whole number. Refer to the following Unit and measurement table.

Treatment services billed in residential programs.
Effective January 1, 2025, PrimeWest Health will no longer require HCPCS code H2036 when billing for Substance Use Disorder (SUD) residential treatment services. Providers must submit all residential treatment claims with RevCode 0944, 0945, or 0953 along with the appropriate Value24Code. Refer to the Minnesota Department of Human Services (DHS) Room and Board 5-digit Value 24 Codes 09/30/2020 reference sheet for a complete listing of codes.

ASAM level 3.1 providers must provide at least 5 of skilled treatment services per week. Providers who have attested to the ASAM 3.1 level of care and are receiving reimbursement at the medium intensity per diem rate must provide at least 15 hours of skilled treatment services per week. The hours must be provided based on the actual count of continuous minutes of treatment service provided. Breaks may not be included in these continuous minutes.

ASAM levels 3.3 and 3.5 must provide skilled treatment services seven days a week.

How to determine missed services in residential levels of care

Programs can continue to bill services based on a member’s intensity level when a treatment service is missed when certain conditions are met. The reason for missing a service must be person-centered, and the program must document both the reason for the member’s absence and the interventions taken.

Holiday scheduling flexibility

Treatment week services hours in outpatient treatment and ASAM level 3.1 residential treatment may be reduced to accommodate Federally recognized holidays. ASAM levels 3.3 and 3.5 must continue to provide a skilled treatment service daily.

Billing for withdrawal management services

The following services are bundled in withdrawal management treatment and cannot be billed separately under substance use disorder services: 

• Comprehensive assessment
• Treatment coordination 
• Peer support services
• SUD-MOUD services including SUD-MOUD-methadone, SUD-MOUD-other, SUD-MOUD-methadone plus, and SUD-MOUD-other-plus 

For a list of services included in the per diem rate, review the Withdrawal Management area of the Substance Use Disorder (SUD) Services section of the PrimeWest Health Provider Manual. 

Billing freestanding and residential program room-and-board charges for PrimeWest Health members

Bill freestanding or residential program room-and-board charges (revenue codes 1002 and 1003) that are authorized by PrimeWest Health to MHCP using MN–ITS Direct Data Entry (DDE) or Batch. Report the following information in the “Value Code” field:

• Value code 80 and the number of inpatient covered days
• Enter value code 24 with the correct five-digit rate code from the Value Code 24 MCO Room and Board Billing list that corresponds to the listed service combinations

A service agreement is not required. Do not report a service agreement number on the claim.

PrimeWest Health continues to be the placing authority for enrolled members. Therefore, PrimeWest Health requires notification for some services for PrimeWest Health members. The following SUD services require notification to PrimeWest Health: 

• Hospital-based inpatient treatment
• Residential treatment
• Nonresidential treatment with dates of services prior to January 1, 2026
• Opioid treatment programs (OTP) with dates of services prior to January 1, 2026

Do not bill for services that require PrimeWest Health notification for which required notifications have not been submitted or for services that are in an Appeal process until the services are authorized.

Telehealth

Telehealth is the delivery of health care services or consultations through the use of real time, two-way interactive audio and visual communications. Telehealth provides or supports health care delivery and facilitates the assessment, diagnosis, consultation, treatment education, and care management of a patient’s health care while the patient is at originating site and the licensed health care provider is at a distant site.

Covered Services

The following medically necessary SUD services provided by eligible SUD providers via telehealth are covered:

• Comprehensive assessments
• Individual and group treatment services
• Peer recovery support services

Billing

Providers who have an approved Telehealth Provider Assurance Statement (DHS-6806) on file with MHCP who submit professional claims for services via telehealth should use claim format 837P (professional).

Use the appropriate place of services that identifies the location of the recipient when the service is provided.

• Place of service 02 (newly defined): Telehealth provided other than the patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.
• Place of service 10 (new place of service): Telehealth provided in patient’s home. The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.
• Modifier 93, audio only: Synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunications system. MHCP requires modifier 93 when audio-only telehealth is used.

Individual and group treatment services (H2035 and H2035 HQ) are billable on the 837I with type of bill 89X and modifier GT.

Type of Bill (TOB)

Enter the appropriate code in the TOB field:

1. 011x is for hospital-based residential treatment
2. 013x is for acute care hospital outpatient services
3. 086x is for the treatment and room and board components of non-hospital-based residential treatment.
4. 089x is for non-hospital-based outpatient treatment

Numeric values for frequency (fourth digit) are as follows:

1. –xxx1: Admit to discharge. This frequency code cannot be used if the patient status is “still a patient” (30) or “expected to return for outpatient services.” It is valid to use with patient status codes 01 – 02, 07, and 20.
2. –xxx2: First claim in a series of continuous claims or interim billing. When submitting the first claim, the admission date field must be the same as the statement date.
3. –xxx3: Continuous claim or interim billing
4. –xxx4: Discharge claim. This frequency code cannot be used if the patient status is “still a patient” (30).
5. –xxx7: A replacement claim
6. –xxx8: A void claim

Disclosing 42 CFR Part 2 Information for Payment

When Part 2-protected information is disclosed for payment purposes through claim submission, the required Part 2 confidentiality notice and summary of consent must be included on the claim. This requirement is satisfied by entering one of the following claim notes exactly as indicated below:

Claim Loop 2300, Segment NTE
NTE01 = ADD
NTE02 = Include one of the following:

"42 CFR Part 2 prohibits unauthorized use/disclosure – TPO on file"
OR
"42 CFR Part 2 prohibits unauthorized use/disclosure – <description of patient's consent>*"

*Note: If entering the second option, be sure to replace “<description of patient’s consent>” with a brief description of what information the patient has agreed to disclose and to whom. 

Providers are not required to submit a copy of the patient’s consent form with each claim. If a provider chooses to submit the consent form as an attachment, it must be identified using the PWK segment (Loop 2300) with Report Type Code CK (Consent Form).

These requirements help to ensure that anyone receiving Part 2-protected information understands the patient’s authorization, knows how the information may be used, and recognizes the confidentiality protections that still apply after the disclosure.

The following SUD claim types must be submitted with a primary diagnosis code (F10 – F19):

• R0900
• R0919
• H2036
• H2035
• H0038 with U8 modifier,
• T1016 with U8 and HN modifiers
• H0001
• H0047
• H0020

Comprehensive assessments (H0001) may be billed with one of the following Z codes as the primary diagnosis if the member does not meet the criteria for a SUD diagnosis:

• Z03.89
• Z71.1
• Z13.39

Discharge Status

Inpatient: Assign the appropriate status for the member that reflects the TOB submitted for the claim. Please refer to Billing Requirements for more information.

Providers are responsible for checking eligibility for members to determine the existence of a copay and for collecting it from the member. Refer to the 2026 Group/Division Benefits Provider Reference Chart for guidance.

Members who have a Medical Assistance (Medicaid) basis of eligibility cannot have services withheld due to an inability to meet their copay responsibility. Providers must follow the PrimeWest Health copay policy found in Billing Requirements under Copay Guidelines.

Medicare

Billing procedures do not change for Medicare members who receive Behavioral Health Fund (BHF) authorization for SUD treatment, unless the provider is an enrolled Medicare program. Medicare programs must follow the PrimeWest Health Medicare policy found in Billing Requirements.

Third Party Liability (TPL)

For dates of service on or after July 1, 2008, PrimeWest Health TPL policy applies to all SUD treatment programs. When a member has private commercial insurance, the SUD treatment program must first bill the private commercial insurance prior to billing PrimeWest Health.

Check eligibility of the member prior to submitting bills to PrimeWest Health. If eligibility information indicates there is TPL for the date(s) the provider would like to bill for, then the provider must first bill the TPL displayed in the PrimeWest Health provider web portal for those date(s). If a program bills PrimeWest Health for dates of service when TPL exists, PrimeWest Health will deny the claim.

Once a provider bills TPL, the provider must submit appropriate coordination of benefits (COB) documentation on their electronic claim submission to PrimeWest Health. Providers must follow the TPL policy (Billing Policy) found in Billing Requirements.

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Updated_03/26/2026