PRIMEWEEKLY FOR CASE MANAGERS
Volume 2, Issue 29 August 18 – 24, 2008
Transition Period for New PrimeWest Health Members
Chris Hagen, PharmD RPh, Utilization Management & Pharmacy Manager
Understanding all of the benefit and coverage policies of PrimeWest Health can be a daunting
task, even for members and providers who are familiar with our programs. Because of this,
PrimeWest Health offers a transitional period for members new to our programs, which allows
them to continue accessing established therapies and services while they become acclimated to
our benefit set. Any member new to PrimeWest Health who identifies him/herself as requiring
special consideration for services established prior to enrollment will be given these transitional
rights. Members may apply for transitional care consideration by doing any of the following:
1. Contacting Member Services at 1-866-431-0801 (toll free)
2. Contacting his/her county worker and filling out a Transition of Care form
3. Filling out a Health Risk Assessment
In addition, the PrimeWest Health Care Coordination team actively searches for members who
require transitional assistance.
During the transition into PrimeWest Health’s programs, our Care Coordination team considers
each member’s individual health concerns and existing services at the time of enrollment.
These may include, but are not limited to, orthodontia, behavioral health, chemical dependency,
high-risk pregnancy, pharmacy utilization, and other conditions or services. The process is
designed to transition new members to contracted network providers and covered services
as seamlessly as possible. New members are required to make the transition from an
out-of-network provider to a participating provider if such a transition will not create undue
hardship on the member and is clinically appropriate.
PrimeWest Health is responsible for ongoing care and will authorize services as needed to
meet the member’s needs. We will not authorize coverage for services that are not part of the
member’s benefits set (as described in the Certificate of Coverage) or services that are excluded
by laws governing Medicaid coverage. Typically, members in transition are granted 120 days of
continuation for the following, unless otherwise noted:
• Continued payment of all eligible drugs the member is taking under a current prescription.
Payment shall continue until a formulary exception is submitted or for 90 days, whichever
occurs first, and will apply to all those members who have been identified as requiring
page 1 of 3
a continuation. This applies to established medications only; new prescriptions require
• An acute condition where the member is engaged in a current course of treatment
• Pregnancy beyond the first trimester. Services will be authorized through the 6-week
• A life-threatening mental or physical illness
• A physical or mental disability constituting an inability to engage in one or more major life
activities, provided that the disability has lasted or can be expected to last for at least one
year, or can be expected to result in death
• A disabling or chronic condition that is in an acute phase
• Presence of a terminal illness where life expectancy is less than 180 days. Authorization will
be extended until the member expires, even if it exceeds the 120-day window.
If new members need transitional assistance for established services—already authorized
by a prior Managed Care Organization (MCO) or the State before enrollment in PrimeWest
Health—please help our Care Coordination team steer them to the proper channels so
continuity of care can be preserved. Please keep in mind that not all services are subject
to transition rights. For questions regarding this policy please contact Chris Hagen,
Utilization Management & Pharmacy Manager, at email@example.com.
Questions and Answers
Elaine Carlquist, BSN, PHN, CCP, Senior Care Coordinator
Beth Pries, MSW, LGSW, Senior Care Coordinator
PrimeWest Health continues to receive great questions from our county case managers. We hope
this periodic question and answer section of PrimeWeekly is a helpful way to share not only the
questions, but also their answers with all of our county partners.
When completing the Skilled Nursing Facility (SNF) Minimum Data Set (MDS) risk assessment,
nursing home staff are asked to use the most recent MDS assessment to answer the questions.
However, answers to some of the questions on the risk assessment are only found on the annual
MDS assessment, which may not be the most current. In this situation, is it okay to use the most
recent as well as the annual MDS assessment to answer the questions?
Yes, is okay to use both of the MDS assessments; however, the most current MDS assessment
should be used whenever possible.
If a county case manager helps a member apply for alternative housing, such as an apartment,
and accompanies the member on a visit to see the facility, can the county case manager bill for
the site visit? page 2 of 3
If a county case manager spends time with a member to help him/her obtain safe and suitable
housing, that time is considered case management time and is billable. Whenever possible,
family or friends should be involved with helping the member find alternative housing, but
if no one else is able to help the member, a county case manager may offer this type of billable
If a resident of a nursing home requests a private room, to whom do we send the request?
For members who reside in Beltrami, Clearwater, and Hubbard counties, direct the
request to Beth Pries, MSW, LGSW, Senior Care Coordinator, at 1-218-308-2807 or
firstname.lastname@example.org. For members of all other PrimeWest Health counties, requests
should be directed to Becki Pender, RN, CCP, Senior Care Manager, at 1-320-335-5204,
1-888-588-4420 ext. 5204, or email@example.com.
Important 2008 Dates
9 Public Health and Human Services Supervisor meetings
August 28, 10 a.m. – 3 p.m.* October 23, 10:30 a.m. – 2:30 p.m.
September 25, 10:30 a.m. – 2:30 p.m. December 11, 10:30 a.m. – 2:30 p.m.
*Due to a full agenda, the Public Health and Human Services Supervisor meeting on
August 28 will start earlier and end later than usual. The time scheduled for the meeting is
10 a.m. – 3 p.m. The meeting agenda will be sent to supervisors by August 22.
All meetings will be held at the PrimeWest Health office in Alexandria unless otherwise
The county case manager educational session will be October 24, 9 a.m. – 12 p.m. The location of
the county case manager session will be announced.
You can find a PDF copy of PrimeWeekly for Case Managers by going
to our website and clicking on Partners & Providers>Resources> Forms, Letters, and
Main Ofﬁce Northern Ofﬁce
2209 Jefferson St, Ste 101 3124 Hannah Ave NW
Alexandria, MN 56308 Bemidji, MN 56601