Billing Requirements

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all health care providers and payers nationwide to use a universal set of standards for electronic billing and administrative transactions (e.g., health care claims, remittance advice [RA], eligibility verification requests, referral authorizations, and coordination of benefits). HIPAA affects PrimeWest Health providers and billing organizations in the following ways:

  1. In order to meet HIPAA requirements and improve customer service to providers and electronic billers, PrimeWest Health has grouped all electronic claim submission processes into a Federally mandated HIPAA‑compliant electronic format
  2. Federal HIPAA rules for information privacy (outlined in the Minnesota Department of Human Services [DHS] Data Privacy notice) change the ways in which protected health information is stored and shared within and between health care organizations

Submitting Rates to PrimeWest Health

If a provider is paid on a per diem basis or a set facility rate, it is the provider’s responsibility to submit rates to PrimeWest Health and update PrimeWest Health with any changes to the rates prior to the submission of claims for that rate period. Once PrimeWest Health receives the updated rates, please allow up to 15 business days for programming of the rates to be completed. PrimeWest Health will not reprocess claims received prior to the date the change is made in our system.

Providers should email or fax all rate updates and changes to PrimeWest Health at the following:

Email: claims@primewest.org
Fax: 1-320-762-1805

PrimeWest Health requires all Critical Access Hospital (CAH) and Rural Health Clinics (RHC) providers to fax or email rates for claims processing on a quarterly basis. PrimeWest Health follows up with contracted providers on a quarterly basis to verify their current per diem rate.

PrimeWest Health will process all claims with the current per diem rates on file at PrimeWest Health at the time the claim is received, regardless of participating or non-participating provider status with the PrimeWest Health provider network. If the current rates on file were received more than one year ago, claims will deny. Providers must send updated rates and resubmit the claim to be considered for reimbursement.

Expectations for Clearinghouses and Billing Intermediaries

Use Only HIPAA-Compliant Electronic Billing Formats

Clearinghouses (X12 Billers)

  1. PrimeWest Health accepts electronic health care transactions in the appropriate X12 batch format
  2. PrimeWest Health will accept interactive (direct data entry) transmissions from a clearinghouse

Billing Intermediaries

PrimeWest Health accepts electronic health care transactions as individual (direct data entry) claims in the appropriate X12 batch format.

Billing PrimeWest Health – Order of Payers

PrimeWest Health pays for services after the member has used all other sources of payment. PrimeWest Health is the payer of last resort. The order of payers for a PrimeWest Health member is as follows:

  1. Third party payers or primary payers to Medicare (e.g., large and small group health plans, private health plans, group health plans covering the beneficiary with End Stage Renal Disease [ESRD] for the first 18 months, Workers’ Compensation law or plan, no-fault or liability insurance policy or plan)
  2. Medicare
  3. PrimeWest Health Medical Assistance (Medicaid) or MinnesotaCare
  4. PrimeWest Health services programs or Alternative Care (AC) program

Providers must bill all third party payers, including Medicare, and receive payment to the fullest extent possible before billing. PrimeWest Health becomes the payer only after all other pay options (other than a Medical Assistance [Medicaid] waiver program) have been exhausted. Services that could have been paid by Medicare, a health maintenance organization (HMO), or insurance plan, if applicable rules were followed, are not covered by PrimeWest Health.

    Timely Filing Requirements

    1. Claims must be submitted correctly and received by PrimeWest Health no later than 180 days from the date of service (DOS). Medicare and TPL claims must be received within 180 days of payment resolution with the primary payer.
    2. Corrected claims must be submitted and received by PrimeWest Health within 180 days from the date of the RA
    3. Claims that do not automatically cross over from Medicare must be submitted and received by PrimeWest Health within 180 days from the Medicare determination or adjudication date or within 180 days from the DOS, whichever is greater
    4. Claims denied due to enrollment changes may be submitted to PrimeWest Health within six months from DOS or date of county correction, whichever is greater
    5. Claims with dates of service older than 34 months will be denied

    Fee-For-Service Payment Methodology

    To determine your payment methodology, refer to Appendix A in the PrimeWest Health Provider Participation Agreement.

    1. Services provided by a physician assistant (PA) shall be paid to the supervising enrolled provider at the lower of the:
    1. Provider’s submitted charge; or
    2. 90 percent of the allowable.
    1. Services provided by an enrolled advanced practice registered nurse (APRN) shall be paid at the lower of:
    1. Provider’s submitted charge; or
    2. 90 percent of the allowable.
    1. Services provided by an enrolled Clinical Nurse Specialist (CNS) shall be paid be paid at the lower of the:
    1. Provider’s submitted charge; or
    2. 90 percent of the allowable.

    Overpayments Received by Providers

    Contracted providers must report to PrimeWest Health when they receive an overpayment from PrimeWest Health. Providers are required to return the overpayment within sixty (60) calendar days after the date on which the overpayment was identified, and to notify PrimeWest Health of the reason for the overpayment, pursuant to section 1128J(d) of the Social Security Act.

    Refer to Refund of Payment in the Claims Payment section for more information.

    Overlapping Minnesota Health Care Programs (MHCP) and PrimeWest Health Coverage

    In certain circumstances, a member could have both Medical Assistance (Medicaid) and MinnesotaCare coverage that overlaps for a short span. See Minnesota Health Care Programs (MHCP) for more information on the programs. The following is an example of verifying eligibility when programs overlap:

    Major Programs: This subscriber has eligibility for MA: Medical Assistance

    Prepaid Health Plan: This subscriber receives (product code) – MinnesotaCare delivered through PrimeWest Health

    If the member has overlapping coverage for the dates of service provided, bill the MCO as primary and MHCP fee for service as secondary for cost sharing. See the following for billing instructions.

    When billing claims to MHCP, do the following:

    1. Send electronic claim attachment
    2. Send cover sheet that states the member has overlapping coverage for dates of service
    3. Attach MCO explanation of benefits (EOB)
    4. Complete the coordination of benefits (COB) information on claim

    When billing for pharmacy claims, do the following:

    1. Enter the coordination of benefits (COB) information on the claim
    2. Submit the claim; the claim will deny with NCPDP reject code “AF”
    3. Contact the MHCP Provider Call Center to create a case to be sent to the claims unit
    4. The pharmacy will be contacted with payment information after the claims unit reprocesses the claim

    Billing Education

    Providers may request a training session on proper billing for covered services by contacting the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

    Notice of Offshore Activities

    Provider shall not itself perform any function, activity, or service pursuant to its Provider Agreement outside the territory of the United States of America, without the prior written consent of PrimeWest Health. In addition, Provider shall not, in connection with any function, activity, or service related to its Provider Agreement, directly or indirectly contract with any person or entity to fulfill any of Provider’s obligations, in whole or in part, where such person or entity is located or may perform such services outside the territory of the United States of America, without the prior written consent of PrimeWest Health. Any consent required by this paragraph must be obtained at least ninety (90) days in advance of any proposed offshoring of services, unless PrimeWest Health agrees in writing to a shorter period of time. If PrimeWest Health gives consent to Provider under this paragraph, PrimeWest Health reserves the right to later revoke such consent if PrimeWest Health is required to do so due to any regulatory or other legal requirement as determined by PrimeWest Health. With respect to any offshoring of services approved by PrimeWest Health, Provider must demonstrate compliance with the Centers for Medicare & Medicaid Services (CMS) and PrimeWest Health requirements, including promptly providing information necessary to support CMS reporting requirements. 

    If you plan to or have been offshoring any PrimeWest Health data, please complete and submit the Offshore Subcontractor Form.

     

    PW_03-19_109
    Updated_05/25/2025