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
Non-Covered Services
PrimeWest Health will not reimburse for the following services/situations:
- Skilled services provided by a program that is not licensed by the commissioner
- Skilled services provided by a non-licensed program
- Services not included in a program’s assurance statement filed with Minnesota Health Care Programs (MHCP)
Services provided by a non–MHCP-enrolled program - Services provided on or after January 1, 2024, by a residential treatment program licensed under MN Stat. sec. 245G.21, out-of-state residential substance use disorder (SUD) providers enrolled with MHCP, and withdrawal management programs not enrolled in the 1115 waiver demonstration
- Services provided by individuals, except as allowed for non-skilled services and individuals licensed as private practice providers
- Room and board services, with the exception of room and board services for members enrolled in MinnesotaCare. Room and board claims for members in all other programs must be submitted to MHCP using MN–ITS.
- Comprehensive assessments completed by non-qualified assessors
- Services delivered to individuals who are not clinically eligible for PrimeWest Health coverage
- Services provided by counties, recovery community organizations, and licensed professionals in private practice delivered prior to the completion of a comprehensive assessment
- Inpatient, residential, and non-residential services provided without notification to PrimeWest Health
- Outpatient substance use disorder treatment and medications for opioid use disorder treatment without notification for dates of services prior to January 1, 2026
- Detoxification except for acute, medically necessary treatment
- Comprehensive assessment, treatment coordination, peer recovery support, and non-residential treatment services when provided by the residential provider receiving a per diem payment for the same date of service and for the same member
- Comprehensive assessments, room-and-board services not clinically or medically necessary, additional SUD treatment services or complexities added to the per diem rate, detoxification services, or Substance Use Disorder Medications for Opioid Use Disorder (SUD-MOUD) guest dosing while a member is receiving treatment in a withdrawal management program
- Services delivered at one location and being billed to another location
- SUD-MOUD guest dosing
PW_11-19_591
Updated_12/16/2025
