Medical, Dental & Pharmacy

Covered Services

PrimeWest Health covers NEMT services when provided for an eligible PrimeWest Health member to or from the site of a PrimeWest Health-covered medical service and services are provided by an enrolled PrimeWest Health care provider (ambulance and non-emergency medical transportation [NEMT]).

Arranging Transportation

Members can arrange for transportation as one-way or round trip within the 30- or 60-mile limit criteria (30 miles for a trip to a primary care provider or 60 miles for a trip to a specialty care provider).

After Hours Policy

Transportation after hours is for transportation that is before 7 a.m. and after 6 p.m., Monday through Friday and all day on weekends and holidays. After-hours transportation is a covered service under PrimeWest Health; however, PrimeWest Health does not require providers to provide transportation services outside of the provider’s business hours. NEMT providers may have hours that are different from those listed above.

Responsible Person

NEMT services may be provided for the member and, when necessary, one responsible person. The responsible person is included in the reimbursement for ground transports.

In most situations, the responsible person must be transported with the PrimeWest Health member to receive payment or reimbursement for the NEMT services. An eligible responsible person includes, but is not limited to, one of the following:

  1. Immediate family
  2. Legal guardian
  3. Authorized representative
  4. Other relatives

Family Members Transported without the Member

PrimeWest Health covers transportation of responsible individuals and one or more siblings from a single location separately from the member when necessary to enable family therapy services as established in the member’s plan of care to be completed. For example, the responsible person, sibling, or spouse of a child or parent living in a residential facility may be required to attend therapy sessions or complete therapy services. Such cases do not require the member receiving care to be included in the transport. Use the member’s PrimeWest Health ID number when billing.

Transportation of an Unaccompanied Minor

PrimeWest Health requires a parent or legal guardian to sign an Unaccompanied Minor Transport Form to allow any minor under age 18 to receive nonemergency medical transportation services to medical, dental, or therapy appointments without being accompanied by a parent or legal guardian.

PrimeWest Health must receive the signed Unaccompanied Minor Transport Form before scheduling any transportation for a minor traveling without a parent or legal guardian. The signed Unaccompanied Minor Transport Form is valid for one year from the date PrimeWest Health receives the signed authorization. The signed Unaccompanied Minor Transport Form is attached to the member’s medical record.

Note: Minors receiving family planning services are not required to have a responsible person accompany them to or from the family planning services and are not required to provide any type of release from a parent or legal guardian.

PrimeWest Health NEMT providers must do the following when transporting a minor:

  1. Verify that parental authorization is in the member’s file unless the member is receiving family planning services.
  2. If in the file, schedule the trip following the call intake process
  3. If no parental authorization is on file, do the following:
    1. Request fax, email, or mailing address information for the parent or guardian of the minor.
    2. Fax, email, or mail request for authorization to the parent or guardian.
    3. Notify the parent or legal guardian if the transportation provider or time of the transport changes
    4. Schedule the trip when signed authorization is received

The local agency-established unaccompanied minor transport form should include, but is not limited to, the following information:

  1. Local agency or coordinator letterhead
  2. Statement of purpose of the unaccompanied minor authorization form
  3. Member’s PrimeWest Health ID number
  4. Member’s name
  5. Date of appointment
  6. Time of appointment
  7. Appointment transport pick-up (origination) location address
  8. Appointment transport drop-off (destination) location address
  9. Parent or guardian’s statement of approval of transport
  10. Parent or guardian’s name printed (with exceptions as listed above)
  11. Parent or guardian’s signature
  12. Date release signed.
  13. Emergency contact number
  14. Emergency drop-off location

Service Animals

Under the Americans with Disabilities Act (ADA), a service animal is any dog that is individually trained to do work or perform tasks for the benefit of a person with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. Other species of animals whether wild or domestic, trained or untrained, are not service animals for the purpose of this definition. In addition to dogs, the ADA allows miniature horses to be service animals if they have been individually trained to do work or perform tasks for the benefit of the person with a disability.

Recurring Trips

A recurring trip is when a PrimeWest Health member needs transportation to appointments with sequential dates and times on a daily, weekly, or bi-weekly basis for an extended period. PrimeWest Health members may schedule recurring trips for up to 30 days at a time in most cases. Members may schedule for more than 30 days in advance for the following conditions or services (including but not limited to):

  1. Dialysis
  2. Child day treatment programs (e.g., Fraser, Lazarus)
  3. Chemotherapy
  4. Dialectical behavior therapy

Transport for Repair of Medical Equipment

PrimeWest Health covers transportation for medical equipment repair only when the member and medical equipment are transported together.

Transportation to an Opioid Treatment Program (OTP)

Providers and drivers must be chosen on a random basis, when feasible, for all NEMT transportation to Opioid Treatment Program (OTP) clinics.

Pharmacy Transports

Allow pharmacy-only transports when transport is the only option available based on pharmacy requirements or absence of other means to obtain the prescription(s). Members must use all means to obtain pharmacy items, including but not limited to the following:

  1. Obtaining the prescription from the out-patient pharmacy at the medical facility or office location
  2. Obtaining prescription(s) while other activities of daily living are completed
  3. Obtaining prescription(s) on return to residence or work from the medical appointment (additional mileage is reimbursable for this purpose)
  4. Using mail, delivery, or courier services

If pharmacy-only transport is required, the following apply:

  1. All prescriptions must be coordinated for pick-up on the same date
  2. Multiple trips per week or per month are not allowed

Multiple Trip Legs

Each complete round trip includes multiple segments by one or multiple transportation providers.

Example

Member is picked up at point A and transported to point B service provider. The transportation provider then transports the member from point B service provider to point C service provider and then to final destination A. This is three trip legs or units.

Transportation between Two Similar or Same Facilities or Locations

PrimeWest Health covers transportation between two hospitals; two LTC facilities; or two medical or residential facilities or other similar or same facilities or locations when a medically necessary health service that is part of the member's plan of care is not available at the originating facility.

The following requirements apply:

  1. The transportation provider must obtain a statement signed by the physician, advance practice registered nurse (APRN), or a member of the nursing staff at the originating facility or location.
  2. The member must be admitted to the final destination hospital, skilled nursing facility (SNF), or medical or residential facility.
  3. For ambulance transportation, use the Ground Ambulance Billing Checklist (DHS-5208A) or Air Ambulance Billing Checklist (DHS-5208).

No-Load Transportation Miles

All no-load miles must be documented with odometer readings on the driver’s trip sheet and billed with modifier "TP" to indicate no-load (member not present) on that specific leg of the trip. 

 

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Updated_05/07/2026