Specialty Provider Direct Access Exception

PrimeWest Health has an exception to the Service Authorization requirements for out-of-plan physician specialists for members in Prime Health Complete (HMO SNP) and Special Needs BasicCare (SNBC), pediatric members (under age 21), as well as a shortage specialty list for all members.

Non-contracted physician specialists are allowed to see members in these groups without a Service Authorization. Please note that physician and dental/oral surgery specialists must still request a Service Authorization for services that require them, regardless of the member’s program, network status of the provider, or whether they are listed on the shortage specialty list.

The exceptions for these groups of members apply only to clinic or outpatient hospital visits provided by a physician specialist listed in the specific groups (below) and diagnostic testing or laboratory services ordered by the same physician specialist. In addition, the exception is only available to physician specialists located in Minnesota, Iowa, North Dakota, South Dakota, and Wisconsin. All other out-of-state specialists require a Service Authorization.

PrimeWest Health follows the specialty designation for out-of-network physicians as listed on the National Plan and Provider Enumeration System (NPPES) Registry in these circumstances.

Direct Access to Pediatric Specialists

The upper age limit for pediatric direct access is 21 (member’s age on the date of service).

  1. The Nurse Practitioner (NP) or Physician Assistant (PA) must have rendered the service in a specialty clinic and must be affiliated with a specialty listed in this list of direct access pediatric specialists. Services will be allowed without an authorization only if the place of service is a specialty clinic. Direct access without an authorization does not apply to NPs and PAs when the services are rendered at a primary care clinic.
    1. Pediatric Specialists Direct Access Listing

Direct Access to Shortage Specialists

PrimeWest Health has a limited number of these specialty types in-network. All member groups are allowed access to these out-of-network specialties without a Service Authorization.

  1. The Nurse Practitioner (NP) or Physician Assistant (PA) must have rendered the service in a specialty clinic and must be affiliated with a specialty listed in this list of shortage specialists. These services will be allowed without an authorization only if the place of service is a specialty clinic. Direct access without an authorization does not apply to NPs and PAs when the services are rendered at a primary care clinic.
    1. Shortage Specialists Direct Access Listing

    Special Needs BasicCare (SNBC) and Prime Health Complete (HMO SNP) Direct Access Specialists

    PrimeWest Health has an exception to the Service Authorization requirement for out-of-plan physician specialists for members in Prime Health Complete (HMO SNP) and Special Needs BasicCare (SNBC).

    1. The condition to pay under the direct access list is that the Nurse Practitioner (NP) or Physician Assistant (PA) must have rendered the service in a specialty clinic and must be affiliated with a specialty listed in this list of direct access specialists. These services will be allowed without an authorization only if the place of service is a specialty clinic. Direct access without an authorization does not apply to NPs and PAs when the services are rendered at a primary care clinic.

      1. Special Needs BasicCare (SNBC) and Prime Health Complete (HMO SNP) Direct Access Specialists Listing​​​​​​

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    Updated_01/20/2023