PrimeWest Health Authorization Criteria

PrimeWest Health requires Service Authorization as a condition of PrimeWest Health payment (regardless of whether PrimeWest Health is primary, secondary, or tertiary insurance for the member) if any of the following apply:

  1. The health service is of questionable medical necessity
  2. The health service requires monitoring to control the expenditure of PrimeWest Health funds
  3. A less costly, appropriate alternative health service is available
  4. The health service is investigative or experimental
  5. The health services is newly developed or modified
  6. The health service is of a continuing nature and requires monitoring to prevent its continuation when it ceases to be beneficial
  7. The health service is comparable to a service provided in a Skilled Nursing Facility (SNF) or hospital but is provided in a member’s home
  8. The health service may be considered cosmetic
  9. Authorization is mandated by the State of Minnesota

Per MN Stat. sec. 62M.09, subd. 3, and in compliance with National Committee for Quality Assurance (NCQA) UM standards, a licensed physician reviews all cases in which the utilization review staff has concluded that the authorization criteria are not met. Under these circumstances, subsequent denials can only be made by a physician reviewer based on medical necessity determinations. The physician reviewer is licensed in the State of Minnesota and is reasonably available by telephone to discuss the determination with the attending health care professional.

Approval and denial letters will be sent to the address provided on the authorization request form that was submitted by the provider.

Previously Authorized Services for New Members

PrimeWest Health follows established procedures for transitioning newly enrolled members. During the transitional process, PrimeWest Health considers the member’s individual health concerns and existing services at the time of enrollment and makes efforts to seamlessly transition new members to contracted network providers for covered services. When considering requests for authorization for continued services from an out-of-plan provider, PrimeWest Health requires that new members transition their health care services to a participating provider, provided that such transition does not create undue hardship on the member and the transition is clinically appropriate.

PrimeWest Health provides all members with medically necessary covered services that an out-of-plan provider, another health plan, or the State had authorized before enrollment in PrimeWest Health. PrimeWest Health may require the member to receive the services by a PrimeWest Health provider, if such a transfer would not create undue hardship on the member and is clinically appropriate.

Documentation Requirements

The criteria listed below are used by PrimeWest Health Utilization Review when processing requests for authorization. To merit authorization, the service must be all of the following:

  1. Medically necessary, as determined by prevailing medical community standards or customary practice and usage
  2. Appropriate and effective for the member’s medical needs
  3. Timely, considering the nature and present medical condition of the member
  4. Provided by a provider with appropriate credentials
  5. The least expensive, appropriate alternative available
  6. An effective and appropriate use of PrimeWest Health funds

Modifiers

If a modifier is required for a particular procedure code, the request for Service Authorization submitted to PrimeWest Health must include the modifier. Information on the approved authorization, including the procedure code(s) and the modifier(s), must match claim information for the service, or the claim will be denied.

All Other Services

The following health services require authorization:

  1. All air ambulance transportation that originates from or is to a destination outside of Minnesota and is to and/or from an out-of-network or out-of-plan provider
  2. Investigative health services and procedures that may be considered cosmetic. If staged reconstructive surgery is being proposed for correction of a congenital anomaly, the complete plan for future surgeries must be submitted with the first authorization.
  3. All surgical or behavioral modification services aimed specifically at weight reduction
  4. Services provided outside of Minnesota. This requirement for prior authorization does not include emergency services. A Service Authorization is required before providing non-emergent services needed because the member’s health would be endangered if the member were required to return to Minnesota. A Service Authorization is also required for services provided to children placed outside of Minnesota through the subsidized adoption assistance program under MN Stat. sec. 256B.055, subd. 1 or 2.

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Updated_02/06/2020