Service Authorization

Some PrimeWest Health-covered services require authorization. The Service Authorization requirement is used to safeguard against inappropriate and unnecessary use of health care services. Some authorization requirements are governed by State law and Federal regulations. When members have private insurance, providers must follow authorization and other rules that apply to the primary insurance.

Providers should obtain Service Authorization (Medical Service Authorization Request Form) prior to providing a service. The Service Authorization requirements apply when PrimeWest Health is primary, secondary, or tertiary payer for the member. There is an exception when Medicare fee-for-service (FFS) is primary: if Medicare pays for any service, PrimeWest Health does not require authorization. If Medicare denies or does not cover any service, all PrimeWest Health authorization rules apply.

Requests for authorization after the service has been provided are subject to the same review criteria as those that are received prior to providing the service.

Expedited Service Authorizations are for cases where the provider indicates or PrimeWest Health determines that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function. If the request does not meet the definition of an expedited Service Authorization, providers should refrain from noting “urgent” on the request.

Receiving an approval for a Service Authorization request does not guarantee payment. Providers must follow PrimeWest Health billing policy guidelines, and the PrimeWest Health member must be eligible at the time the service is rendered.

All PrimeWest Health Utilization Management (UM) determinations are based only on the appropriateness of care and service and coverage. PrimeWest Health does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial or other incentives for PrimeWest Health UM decision-makers to encourage decisions that result in underutilization.

Out-of-Country Care

PrimeWest Health does not cover emergency or other health care services received from providers located outside the United States. For the purpose of this section, United States includes the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Notice of Action Taken

PrimeWest Health will notify the provider by telephone and in writing and the member in writing of action taken on an authorization request. PrimeWest Health Utilization Review will notify the provider if additional information is needed to determine medical necessity. If a request is denied, the member and provider will receive a notice of the member’s right to Appeal.

Peer-to-Peer Conversation

PrimeWest Health professionals who conduct clinical review of Service Authorization requests are available to discuss review determinations with attending physicians or other ordering providers. This review can occur by telephone, in person, or by secure email. Providers who wish to discuss review determinations with the professional clinical reviewer should contact PrimeWest Health’s Quality & Utilization Management department Monday – Friday, 8 a.m. – 4:30 p.m., at 1-866-431-0803 (toll free) to request a peer-to-peer conversation. The peer-to-peer conversation may be conducted by the physician who made the initial decision, or if that reviewer is not available, with another clinical peer, within one business day of the request. This peer-to-peer conversation is not considered an Appeal.

Availability of Utilization Management Criteria

The PrimeWest Health Quality & Utilization Management department uses the most current InterQual® criteria; adopted clinical practice guidelines; Minnesota Department of Human Services (DHS) policies; State of Minnesota coverage policies; Centers for Medicare & Medicaid Services (CMS) national coverage determinations (dual eligible members only); local Medicare coverage determinations published by National Government Services (NGS) for Part B services and Celerian Group Company (CGS) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and other PrimeWest Health-approved medical policies in its authorization decisions. Criteria are available upon request of the practitioner. The practitioner may request the criteria either by phone, fax, email, via the PrimeWest Health provider web portal, or by written request sent via the United States Post Office. The criteria will be provided to the practitioner upon request through any of the distribution methods listed above or in person.

Criteria can also be accessed at the following:

Health Plan Appeals and State Appeals (formerly known as Appeals and State Fair Hearings)

If the member disagrees with a decision or has a complaint about their health care, services, or coverage, they may file a Grievance (complaint) or Appeal using the online PrimeWest Health Member Appeal and Grievance Form. If the member does not agree with the outcome of the health plan Appeal, they can request a State Appeal. The member can request a State Appeal in the following ways:

Write to:
Minnesota Department of Human Services
Appeals Office
PO Box 64941
Saint Paul, MN 55164-0941

File online:
https://edocs.dhs.state.mn.us/lfserver/Public/ DHS-0033-ENG

Or fax to:
1-651-431-7523

The member can also file a complaint (Grievance) with the Minnesota Department of Health in the following ways:

Write to:
Minnesota Department of Health
Managed Care Systems Section
PO Box 64975
St. Paul, MN 55164-0975

Call:
1-800-657-3916 or 1-651-201-5100 (TTY 711)

File online:
https://www.health.state.mn.us/facilities/insurance/managedcare/docs/hmoform.pdf

The member can call or write to the Ombudsperson for Public Managed Health Care Programs. The Ombudsperson may be able to help the member with access, service, or billing problems. The Ombudsperson can also help the member file a Grievance or Appeal with PrimeWest Health or request a State Appeal.

To contact the Ombudsperson for Public Managed Health Care Programs, call 1-800-657-3729 (toll free, non-metro area) or 1-651- 431-2660 (Twin Cities metro area) or TTY 711. Hours of service are Monday – Friday, 8 a.m. – 4:30 p.m.

Providers may submit additional documentation and ask PrimeWest Health for a reconsideration of a decision. This can be done by submitting a Provider Appeal Form to PrimeWest Health’s Member & Provider Services department. For more information about provider Appeals, please refer to your provider contract or call the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

Service Authorization Requests and Medicare or Third-Party Liability (TPL) Coverage

Except for home care and Early Intensive Developmental and Behavioral Intervention (EIDBI) authorization requests, PrimeWest Health will not consider a request for authorization of a service or item for a member with Medicare or TPL coverage unless the provider has made a good faith effort to receive authorization or payment from the primary payer(s).

For services or items, document and submit to the review agent the good faith effort with any of the following:

  • An explanation of benefits (EOB) showing determination of payment by the primary payer(s)
  • A determination of authorization or denial of authorization by the primary payer(s)
  • Written communication from the primary payer(s) showing that the service is not covered for the member
  • Documentation by the provider of a phone call to the primary payer(s) and the statements made by the primary payer about coverage of the service or item for the member
  • Documentation by the provider that, because of recent claim experiences with Medicare, coverage is not available for the service or item

If a Minnesota Information Transfer System (MN–ITS) authorization response shows TPL coverage, include a printout of the authorization response with submitted documentation.

Except for home care services, authorization is not required if a third party payer has made payment that is equal to or greater than 60 percent of the PrimeWest Health maximum allowed amount for the service or item. Submit the claim to Minnesota Health Care Programs (MHCP) and attach the EOB from the other payer(s) to the claim. For more information, review the Medicare and Other Insurance section of the DHS Provider Manual.

Medical Necessity Review

If there is concern about TPL coverage ending before treatment is complete, submit a Service Authorization request and include documentation of a good faith effort as outlined in the previous section, and a statement indicating that the request is for medical necessity review in case of loss of insurance.
If the medical necessity review is:

  • Approved: The provider should bill PrimeWest Health as a secondary payer with TPL coverage as the primary payer until the TPL coverage ends, at which point the provider should bill MHCP as the primary payer.
  • Denied: The provider may obtain a signed Advance Recipient Notice of Non-covered Service/Item (DHS-3640) and receive payment from the member for the service or cost sharing. If the member chooses not to sign the Advance Recipient Notice of Non-covered Service/Item, the provider may decline to provide the service, and must not bill the member or MHCP for any service cost, including cost sharing as secondary payer.

Retroactive Medical Necessity Review

If the service has begun without a PrimeWest Health medical necessity determination and TPL coverage ends, MHCP will pay for the remainder of the service only if the applicable Service Authorization criteria would have been met when the service began. Request a retroactive Service Authorization review.

If the retroactive Service Authorization review is:

  • Approved: The provider may bill PrimeWest Health as the primary payer after the last TPL payment is made.
  • Denied: The provider may not bill the member or PrimeWest Health for any service cost, including cost sharing.
     

PW_03-19_101
Updated_05/22/2025