Out-of-Network Providers

Out-of-network providers are providers that do not have a direct contract with PrimeWest Health. In most circumstances, PrimeWest Health members must see in-network providers. Except for emergency services, out-of-network providers must obtain prior authorization before providing PrimeWest Health-covered services. Requests for prior authorization of services provided outside of the PrimeWest Health network or by non-contracted providers in or out of state must include documentation establishing medical necessity and the unavailability of that service in Minnesota or in the PrimeWest Health network. PrimeWest Health-covered services provided to a Minnesota member by an out-of-state, out-of-network provider are covered under the following circumstances:

  • The services are medically necessary;
  • The services are provided in response to an emergency while the member is out of the state and the provider is not part of the PrimeWest Health network;
  • The services are not available in-network or by an out-of-state contracted provider, and the attending physician has determined medical necessity and obtained prior authorization from PrimeWest Health.
  • The cost to the member is no greater than it would be if the services were furnished in-network. (The county is responsible for travel expenses associated with obtaining the out-of-state services.); or
  • The services are required because the member’s health would be endangered if they were required to return to Minnesota or to an in-plan or in-network provider for treatment.

There is an exception to the Service Authorization requirement for out-of-network providers for Prime Health Complete (HMO SNP) and Special Needs BasicCare (SNBC) members and pediatric members (under 21 years of age). Non-contracted physician specialists are allowed to see members in these groups without a Service Authorization. This exception for these groups of members applies only to clinic or outpatient hospital office visits provided by physician specialists (example: cardiology, pulmonology, pediatric endocrinology, neurosurgeons, infectious disease specialists, rheumatologists, oncologists, gastroenterologists, dermatologists, plastic surgery, etc.) and diagnostic testing or laboratory services ordered by the same physician specialists.

For more information on the Service Authorization requirements and processes, review the Service Authorization page.
 
PrimeWest Health requires all providers providing service to members to be a Minnesota Health Care Programs (MHCP) provider. Please see the MHCP Provider Enrollment Page for details on how to enroll.

Claims and Billing

If you are a new provider serving PrimeWest Health members, review the Out-of-Network Facility Registration Requirements page to be set up in PrimeWest Health’s system prior to submitting your first claim. When submitting claims, be sure to follow PrimeWest Health Billing Requirements. For assistance with claim submission, review the Claims Submission page.

By agreeing to provide service to a PrimeWest Health member, a provider must accept PrimeWest Health reimbursement as payment in full. There are only a limited number of instances when providers may bill a PrimeWest Health member. Please refer to the Billing a PrimeWest Health Member page for complete details.

If you have specific questions or need assistance, please contact the Provider Contact Center.

Centers for Medicare & Medicaid Services’ (CMS) Merit-Based Incentive Payment System (MIPS)

PrimeWest Health has implemented the Centers for Medicare & Medicaid Services’ (CMS) Merit-Based Incentive Payment System (MIPS) requirement for Medicare-eligible services provided to PrimeWest Health members.

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Updated_12/03/2021