Utilization Management
Practitioner Communication Regarding the PrimeWest Health Utilization Program
Utilization Management (UM) involves a comprehensive, systematic approach to the delivery of effective and appropriate care and services to members. It is designed to coordinate the provision of services to members; promote and assure service accessibility; provide attention to individual needs, continuity of care, and comprehensive and coordinated service delivery; provide culturally appropriate care; and assure fiscal and professional responsibility. As such, PrimeWest Health has created a Utilization Management Plan to address these areas. Components of the Utilization Management Plan provide mechanisms for reviewing, monitoring, evaluating, and improving the utilization of all covered services. This includes behavioral health services, dental services, pharmacy services, chiropractic services, and all medical services.
All UM determinations are based solely on the appropriateness of care and service and the member's coverage. PrimeWest Health does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial or other incentives for UM decision makers to encourage decisions that result in underutilization.
PrimeWest Health utilizes written clinical criteria to ensure consistent, appropriate decision-making regarding care and services. PrimeWest Health uses nationally accepted criteria and follows written policies and procedures that reflect current standards of medical practice, such as InterQual, or other valid criteria (e.g., DHS guidelines) for utilization review decisions. All criteria are well-documented and include procedures for application of the criteria based on the needs of individual patients and characteristics of the local health care delivery system. Actively practicing practitioners from appropriate specialties are involved in the development or adoption of criteria and in the procedures for application of the criteria. The criteria are evaluated annually including InterQual and InterQual updates and are updated as necessary to stay current with evolving standards of medical care. Criteria and/or professional treatment guidelines used to establish medical necessity, appropriateness, and efficacy of a procedure or service are made known to members, practitioners, and regulators upon request. Only licensed practitioners make clinical decisions that require clinical judgment.
PrimeWest Health uses the following clinical criteria to ensure appropriateness of care and service:
- Centers for Medicare & Medicaid Service (CMS) for national coverage determinations and the CGS Administrators, LLC., Jurisdiction B, for local coverage determinations
- Adopted clinical practice guidelines (dual eligible members only)
- InterQual (log in using your PrimeWest Health Provider Web Portal username and password)
- Adopted Department of Human Services and State of Minnesota coverage policies
- Other PrimeWest Health-approved medical policies
- PrimeWest Health General Medical Necessity Criteria
If you have questions about the criteria or would like to request a copy, please call the call the Provider Contact Center at 1-866-431-0802 (toll free).
PrimeWest Health professionals who conduct clinical review of Service Authorization requests are available to discuss reviewer determinations or peer-to-peer conversations with attending physicians or other ordering providers. This review can occur by telephone, in person, or by secure email. Providers who wish to discuss review determinations with the professional clinical reviewer should contact PrimeWest Health’s Quality & Utilization Management department Monday through Friday, 8 a.m. to 4:30 p.m., at 1-866-431-0803 (toll free) to request a peer-to-peer conversation. The peer-to-peer conversation may be conducted by the physician who made the initial decision, or if that reviewer is not available, with another clinical peer within one business day of the request. This peer-to-peer conversation is not considered an Appeal.
PrimeWest Health maintains toll-free telephone and fax numbers to allow access to staff during normal business hours, Monday through Friday, 8 a.m. to 4:30 p.m. UM staff can answer questions about UM issues, specific UM cases, or the details of a UM decision. You can contact UM staff by telephone at 1-866-431-0803 (toll free) or by fax at 1-866-431-0804 (toll free). After hours, PrimeWest Health maintains a secure confidential voicemail system where requests can be left. Calls are accepted 24 hours a day, 365 days a year. If you call outside of normal business hours, you will be given instructions about how to leave a voicemail message or send a fax with your question(s). Any calls received after normal business hours are returned the next business day, with the exception of calls received after midnight Monday through Friday, which are returned the same business day. Outgoing calls from PrimeWest Health’s Quality & Utilization Management department require that staff identify themselves by name, title, and organization when initiating or returning calls regarding UM issues. PrimeWest Health offers TDD/TTY services for deaf, hard of hearing, or speech-impaired members. Upon member request, language assistance is available free of charge through bilingual staff or an interpreter. If you have questions regarding Medicare pharmacy services, please call 1-877-391-9294 (toll free). If you have questions regarding Medicaid pharmacy services, please call 1-877-391-9298 (toll free). Providers may also call the Provider Contact Center at 1-866-431-0802 (toll free).
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Updated_01/16/2026
