Enrollment Requirements

All providers that wish to enroll with PrimeWest Health must provide the following:

  1. Disclosure of Ownership and Control Interest of an Entity
  2. W-9 form
  3. National Provider Identifier (NPI) number or Unique Minnesota Provider Identifier (UMPI) number
  4. Proof of applicable insurance coverage
  5. All applicable license(s) for services they provide

Provider Screening and Enrollment

PrimeWest Health reviews provider enrollment records, relying on Minnesota Health Care Program (MHCP) enrollment information to the extent possible to identify providers due for required revalidation.

Providers should check the MN–ITS PRVLTR file regularly for important notices, including letters notifying them that they are due for revalidation. If a provider has not set up a MN–ITS mailbox, MHCP, not PrimeWest Health, sends the notice of revalidation to the credentialing address recorded on the provider’s enrollment record.

MHCP Provider Screening Requirements

MHCP is required to follow the Centers for Medicare & Medicaid Services (CMS) final Federal provider screening regulations that were effective March 25, 2011.

Providers should review MHCP Revalidation for additional details about MHCP provider revalidation.

Risk Levels

CMS has established the following three risk levels for providers: limited, moderate, and high. It has assigned one of these risk levels to each provider type that enrolls with Medicare.

MHCP uses the same Medicare risk levels assigned by CMS for provider types that are eligible to enroll with both Medicare and MHCP. For provider types that are not eligible to enroll with Medicare, MHCP has assigned risk levels.

Refer to Risk Levels and Enrollment Verification Requirements and the Screening Categories section of the CMS Medicare Program Integrity Manual for more information.

MHCP Change of Risk Level

MHCP is required to assign a high-risk level to an individual provider or provider organization when any of the following conditions exists:

  1. A payment suspension is imposed because of a credible allegation of fraud, waste, or abuse
  2. The provider has an existing Medicaid overpayment
  3. The provider has been excluded by the OIG or another state’s Medicaid program within the last 10 years

A provider type is also assigned a high-risk level for the first six months after a state Medicaid agency or CMS lifts a temporary moratorium for that provider type.

MHCP Screening Actions

All providers are subject to some type of screening action. Some screening actions are required for all provider types. Others are specific to provider types with a high or moderate risk level.

MHCP Revalidation

Providers who are currently enrolled with MHCP must revalidate their enrollment record(s) at least once every five years. Revalidation occurs when MHCP notifies providers to complete and update all enrollment documents to continue participation with MHCP. Providers can expect to receive an initial revalidation notice as early as three-and-a-half years after the most recent revalidation or enrollment date.

PCA Agencies Only

If a provider’s enrollment with MHCP ends, the provider must immediately notify the county or counties where their MHCP recipients live. The provider informs the county that the provider can no longer be reimbursed for services as an MHCP provider, and that the county should take actions to ensure the safety of the recipients (Minnesota Stat. sec. 626.557). Terminated personal care assistance (PCA) provider agencies, including all named individuals on the current enrollment disclosure form, and known or discovered affiliates of the PCA provider agency, are not eligible to enroll as a PCA agency for two years following the termination (Minnesota Stat. sec. 256B.0659, subd. 23).

MHCP Site Visits

If the provider type has a moderate or high risk level, MHCP will conduct pre-enrollment and post-enrollment site visits when the provider enrolls, re-enrolls, or revalidates enrollment. The provider must permit MHCP to conduct unannounced, on-site inspections of any of their locations to comply with screening requirements.

MHCP Application Fees

MHCP collects a nonrefundable application fee from “institutional providers of medical or other items or services or suppliers” to fund provider screening costs. If the provider is an institutional provider and is newly enrolling, re-enrolling, or revalidating enrollment, the provider must pay the application fee. Effective January 1, 2018, the fee is $730 per practice location. MHCP has developed a web-based system for providers to submit their fee payments.

General Liability Insurance

PrimeWest Health will, upon initial assessment and confirmation every three years (36 months) during reassessments, obtain a copy of the current general liability insurance certificate for all contracted providers.

  1. PrimeWest Health requires all contracted providers to hold general liability coverage of $1 million per occurrence/$3 million aggregate, effective at the time of assessment and reassessment determinations.
  2. Exceptions will be granted for providers subject to tort liability limitations under State or Federal law for smaller sized medical clinics and outpatient service providers on a case-by-case basis as determined by the Quality and Care Coordination Committee (QCCC)
  3. During assessment and reassessment, contracting staff will verify levels of current general liability insurance.
  4. In the event this information is not provided, or the information is incomplete, contracting staff will request the information from the provider, either in writing or verbally.
  5. If, during the initial assessment, the information provided does not satisfy the requirements and the provider is not willing to increase the coverage, the initial assessment will be returned to the provider as ineligible. If, during the reassessment, the provider does not provide certification showing adequate liability limits, the contract with the provider may be terminated for cause.
  6. All contracted providers will be required to submit proof that they satisfy PrimeWest Health insurance requirements. PrimeWest Health will accept a copy of the declarations page of the policy from the insurance carrier or the provider.

Checking the Federal and State Exclusions Lists

The Federal Health and Human Services Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid, and other Federal health care programs. PrimeWest Health also excludes individuals and entities from participation in PrimeWest Health. PrimeWest Health cannot enroll and pay providers that either the Federal OIG or MHCP have excluded.

Federal Exclusions List

The OIG publishes a list of excluded providers and may impose civil monetary penalties against providers who employ or enter into contracts with excluded individuals or entities to provide services or items to recipients.

Providers who choose to enroll with PrimeWest Health must check all owners, managing employees, board members, employees, or anyone else who works for the provider against the OIG list of excluded individuals and entities (LEIE) The LEIE provides information to the health care industry, patients, and the public about individuals and entities currently excluded.

The effect of an exclusion is that no payment will be made by any Federal health care program for any items or services furnished, ordered or prescribed by an excluded individual or entity. This payment withholding applies to the excluded person and anyone who employs or contracts with the excluded person. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person.

Providers must report to PrimeWest Health any individual or entity they find on the exclusion list. Provider enrollment will also verify the entity and individuals listed above against the LEIE on an ongoing basis to identify and remove any person added to the Federal list of exclusions.

Minnesota Excluded Providers

In addition to the Federal exclusion list, PrimeWest Health maintains and publishes two lists of all people suspended or terminated from receiving payment from Medicaid funds who PrimeWest Health has excluded—one for excluded group providers and one for excluded individual providers. Besides checking the LEIE, providers must also check the Minnesota Excluded Provider lists when employing or entering into contracts with individuals or entities to provide services or items to recipients. PrimeWest Health will deny claims for services or items rendered, ordered, referred, or prescribed by excluded providers.

Providers must verify that all people they employ are not on an exclusion list before hire and on an ongoing basis (at least monthly). Anyone who is on the list is excluded from employment with an entity who receives reimbursement from PrimeWest Health.

Owner information is not included on the individual provider list unless the owner is also enrolled as an individual provider of services.

For individual providers, the list shows the following:

  1. Provider type description
  2. Last name, first name, middle name
  3. Effective date of exclusion
  4. Address line 1 (This is the last known practice, organization, or provider where the person was working)
  5. Address line 2

For group or organization providers, the list shows the following:

  1. Provider type description
  2. Agency name
  3. Effective date of exclusion
  4. Address line 1
  5. Address line 2

The MHCP Excluded Provider Lists are updated monthly.

Providers named on the excluded providers list have been terminated due to fraud, theft, abuse, error, or noncompliance in connection with a Minnesota health care program. PrimeWest Health cannot pay providers on an excluded provider list for services they provide to PrimeWest Health members. Providers are notified that they are being terminated before they are named on the published list. The effective date of nonpayment is the date of the notification. Excluded providers are not prohibited from providing services for private-pay clients.

PrimeWest Health will not pay for services that providers or individual staff members provide to PrimeWest Health members after they have been terminated. If PrimeWest Health has already paid for services and then finds that a provider on an exclusion list performed the service, PrimeWest Health will recover all funds paid.

Contact the PrimeWest Health Provider Call Center to verify information that may not be clear on the list, such as a person with a similar name, or a person with the same name who is shown as a different provider type.

Practitioner Rights

PrimeWest Health Credentialing requires practitioners to submit a written request via mail, email, or fax to review information submitted to support their credentialing application, correct erroneous information, and receive the status of their credentialing or recredentialing application. For further information regarding practitioner rights, please visit our website to view pertinent PrimeWest Health Policies, including the Practitioner Rights Policy and Credentialing Plan.

Use of Billing Agents

If a billing agent (person or entity that submits a claim or receives PrimeWest Health payment on behalf of a provider) is used, the name and address of the billing agent must also be listed on the Participation Request form. PrimeWest Health Provider Services must be notified in writing if a billing agent is hired after enrollment. The notification must include the provider name, NPI/UMPI/, office address, and billing agent’s name and address. Send the notice to:

Attn: Contracting
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Or, email the notification to contracting@primewest.org.

Payment to Provider or Billing Agent

All PrimeWest Health payments must be made to the provider. However, PrimeWest Health payment may be mailed to a billing agent (such as an accounting firm or billing service) that furnishes statements and receives payments in the name of the provider, if the agent’s compensation for these services is all of the following:

  1. Related to the cost of processing the billing
  2. Not related on a percentage (or other basis) to the amount that is billed or collected
  3. Not dependent on collection of the payment

Sale or Transfer of an Entity

A PrimeWest Health provider who sells or transfers ownership or control of an entity that is enrolled in PrimeWest Health must notify PrimeWest Health Provider Services in writing no later than 45 days before the effective date of the sale or transfer via mail or email:

Attn: Contracting
PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

Email: contracting@primewest.org

PrimeWest Health has the right to pursue monetary recovery or civil or criminal action against the seller or transferor.

Affirmative Action Plan Requirement

A provider applying for PrimeWest Health participation that has employed more than 40 full-time employees at any time during the past year, and who anticipates reimbursement in excess of $100,000 in a one-year period, must have an affirmative action plan for the employment of minority persons, women, and the disabled that is approved by the Commissioner of Human Rights. As part of the enrollment process, PrimeWest Health may ask providers to submit documents showing compliance with, or exemption from, the affirmative action requirement plan of the Minnesota Human Rights Act.

Duration of PrimeWest Health Participation

PrimeWest Health participation remains in effect until one of the following occurs:

  1. Either party terminates in accordance with terms specified in the agreement
  2. The provider fails to comply with the terms of participation
  3. The provider sells or transfers ownership, assets, or control of an entity that has been enrolled to provide PrimeWest Health services

For additional information, the provider should refer to the Provider Participation Agreement.

Noninterference with Medical Care

PrimeWest Health will not interfere in any manner in the methods or means by which a provider renders health care services or provides health care supplies to members. PrimeWest Health does not require providers to take any action inconsistent with professional judgment concerning the medical care and treatment rendered to members. Providers may freely communicate with patients about treatment options available to them, including medication treatment options, regardless of benefit coverage limitations.

Providers and PrimeWest Health Quality Initiatives

Contracted providers agree to cooperate with PrimeWest Health quality management initiatives and programs. This includes providing PrimeWest Health, upon request, information needed to assess quality and to participate, cooperate, and assist with audit procedures and access standards.

Providers also agree to allow PrimeWest Health to obtain and use provider and provider’s practitioners’ performance data. Performance data on providers may include facility utilization data, Healthcare Effectiveness Data and Information Set (HEDIS) production and performance evaluation, member satisfaction, overall compliance with the National Committee for Quality Assurance (NCQA) or other comparable quality standards, and data required for compliance with applicable State and Federal requirements.

PrimeWest Health Member Confidentiality

All medical records and other protected health information (PHI) of PrimeWest Health members created or maintained by or in possession of PrimeWest Health and the provider shall be maintained in an accurate and confidential manner in accordance with applicable State and Federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA). All medical records shall belong to the provider consistent with the dictates of medical ethics.

Member Access to Care

In compliance with MN Stat. 62D sec. 124, PrimeWest Health-contracted providers must ensure PrimeWest Health members have access to covered health care services to the same extent available to the general population. Primary care and specialty service providers, including mental health service providers, must provide or arrange for the provision of covered services to members 24 hours a day, 7 days a week, 365 days a year. The provision of services may include the following:

  1. Regularly scheduled appointments during normal business hours
  2. After-hours clinics
  3. Use of 24-hour answering service with standards for maximum allowable call-back times based on what is medically appropriate to each situation
  4. Back-up coverage by another participating primary care or specialty care provider. This on-call provider, or an alternative provider, shall be available to members whenever the primary provider is not available.
  5. Referrals to urgent care centers, where available, and to hospital emergency care (MN Rules part 4681010, subp. 2.A[1] [a – e])

Providers should have normal business hours and instructions for after-hours care posted so members can see the instructions from outside the clinic. The notice should include office hours and phone numbers for after-hours service. The clinic should also have a recorded telephone message after clinic hours instructing members how to access after-hours care and directing members with a life-threatening situation to hang up and dial 911. (MN Rules part 4685.1010; 42 CFR Part 422.111)

Violating Provider Participation Agreement

A provider who fails to comply with the terms of participation in the Provider Participation Agreement or with requirements of the rules governing PrimeWest Health is subject to monetary recovery. The provider may also be subject to MN Rules parts 9505.2160 – 9505.2245, program sanctions, or civil or criminal action. Unless otherwise provided by law, no provider of health care services will be declared ineligible without prior notice and an opportunity for a hearing under MN Stat. secs. 14.57 – 14.62. See MN Rules Chap. 9505.

Distribution of Written Materials to Practitioners

From time to time, PrimeWest Health distributes written materials or information to practitioners. In cases where PrimeWest Health has contracted with the facility or clinic in which the practitioner practices, the written materials or information will be sent to the clinic or facility administrator, office manager, or other designated office staff member. The administrator, office manager, or other designated office staff member is responsible for distributing such written materials or information to the practitioners.

Notification to PrimeWest Health

PrimeWest Health requires providers to report to PrimeWest Health within five days any information regarding individuals or entities within their organization who have been convicted of a criminal offense related to the involvement in any program established under Medicare, Medicaid, the programs under Title XX of the Social Security Act, or that have been excluded from participation in Medicaid under Sections 1128 or 1128A of the Social Security Act.

Terminating Care of a PrimeWest Health Member

If a provider chooses to discontinue care for a PrimeWest Health member, the provider must notify PrimeWest Health and the member in writing, providing a 30-day notice that includes the effective date and reason care will be discontinued. PrimeWest Health is obligated to ensure that members have access to medical care. PrimeWest Health will furnish the member with names, addresses, and telephone numbers of other participating providers in the same area of medical specialty, and a PrimeWest Health care coordinator will assist the member in locating a new medical home.

A provider may discharge a member for any of the following reasons:

  1. The member behaves in a manner that seriously impairs the provider or the provider’s ability to furnish health care services to the member or to other members
  2. The member is uncooperative or abusive toward the provider
  3. The member incurred unpaid bills before enrollment with PrimeWest Health
  4. The inability of the member and the provider to agree on a course of treatment

Please send notification to PrimeWest Health at the following address:

PrimeWest Health
Attention: Provider Relations
3905 Dakota St
Alexandria, MN 56308

Notification can also be faxed to 1-320-762-8750 (attention: Provider Relations).

Limits on Member Services

MN Rules 9505.0195, subp. 10 states in part: 

A provider shall not place restrictions or criteria on the services it will make available, the type of health conditions it will accept, or the persons it will accept for care or treatment, unless the provider applies those restrictions or criteria to all individuals seeking the provider's services. A provider shall render to recipients services of the same scope and quality as would be provided to the general public. Furthermore, a provider who has such restrictions or criteria shall disclose the restrictions or criteria to the department so the department can determine whether the provider complies with the requirements of this subpart.

For example, providers cannot deny treatment for a certain diagnosis (e.g., pregnancy) to PrimeWest Health members unless treatment for that diagnosis is also not available to other patients. Requirements regarding the need for a referral, or which days are available for treatment, etc., are legitimate requirements for PrimeWest Health members only if they are also applied to other patients. Providers must offer to PrimeWest Health members hours of operation that are no less (in number or scope) than the hours of operation offered to non-PrimeWest Health members.

 

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Update_01/14/2026