Provider Notice: WVCHIP Benefit Transition
Please see the following information regarding the ongoing transition to align WVCHIP benefits to WV Medicaid, due to the West Virginia Legislature's, House Bill 4649. Read here to see the complete notice.
Providers: Payment Error Rate Measurement (PERM) Review - Reminder to Submit Medical Records
The Centers for Medicare & Medicaid Services (CMS) Payment Error Rate Measurement (PERM) Program for Reporting Year (RY) 2023 is currently reviewing the WV Medicaid and WV Children's Health Insurance program (WVCHIP) to measure imporoper payments in order to maintain the integrity of the Medicaid program. The Review Contractor (RC) Empower AI is authorized to collect information from providers and to review documentation to ascertain adherence to Medicaid regulations. Please read here for additional information.
Please remind your patients to make sure their addresses are up-to-date with CHIP. Some addresses have been changed by 911, some have been changed because of moving, and other reasons. Click here for more Information.
Provider Enrollment & Registration
Providers may bill WVCHIP electronically through Gainwell Technologies with an active provider enrollment and Trading Partner Agreement (TPA).
Instructions are located at www.wvmmis.com or by calling the Gainwell Technologies Provider Relations department at (888)483-0793.
West Virginia COVID-19 Vaccine Provider Communication Toolkit
Please see the
Communications Toolkit here.
WVCHIP Telehealth Policy
For West Virginia CHIP's Telehealth Policy, please see the following: Telehealth Policy
WVCHIP Has Joined Mountain Health Trust Managed Care Program
7/31/2020 Original Date
The West Virginia Children’s Health Insurance Program (WVCHIP) joined the West Virginia Mountain Health Trust (MHT) managed care program effective January 1, 2021. All currently enrolled WVCHIP providers received a notification letter of this change on or about July 31, 2020. With the transition of WVCHIP members to the MHT program, WVCHIP enrolled members and families will be able to select from one of three MHT managed care plans to serve their health care benefit needs.
WVCHIP providers will receive information from the health plans on how to enroll with them.
State Treasurer's Office's Unclaimed Property Site May Be Helpful to Providers in West Virginia
If you think you could possibly have unclaimed funds in the State of West Virginia, you might want to check this website:
You can also call the State Treasurer's office at 1-800-642-8687
Medicaid and CHIP Allocation
HHS (US Health & Human Services) expects to distribute $15 billion to eligible providers that participate in state Medicaid/CHIP programs or Medicaid managed care plans and have not yet received a payment from the Provider Relief Fund General Distribution allocation.
Where can I find more information? https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html
Also, see the following FACT Sheet for information: https://www.hhs.gov/sites/default/files/provider-relief-fund-medicaid-chip-factsheet.pdf
To Apply: Download the Medicaid Provider Distribution Instructions and Medicaid Provider Distribution Application Form from hhs.gov/providerrelief
Please visit hhs.gov/providerrelief for eligibility requrements, Terms and Conditions, Frequently Asked Questions (FAQs) and a recording of past webinars on the application process. For additional information, please call the provider support line at
(866) 569-3522; for TTY dial 711. Hours of operation are 7 a.m. to 10 p.m. Central Time, Monday through Friday. Service staff members are available to provide real-time technical assistance, as well as service and payment support.
Prior Authorizations Requirements and Prescription Copays will be Reinstated June 15, 2020 - (Update to temporary policies put into place during COVID-19)
The West Virginia Children's Health Insurance Program (WVCHIP) relaxed prior authorization requirments for all medical, behavioral health and dental services, as well as prescription drugs, following the declaration of West Virginia's State of Emergency by Governor Jim Justice due to the COVID-19 pandemic.
See Memo Here
Delivery of Clinical Preventive Services Combined
The COVID-19 pandemic is changing rapidly and continues to affect communities across the United States differently. Clinicians must maintain access to clinical services in environments that are safe for all. Some of the strategies used to slow the spread of disease in communities include postponing or cancelling non-urgent elective procedures and using telemedicine instead of face-to-face encounters for routine medical encounters.
Please see Memo Here:
Delivery of Clinical Preventive Services Combined.pdf
Coronavirus (COVID-19) Policy
The West Virginia Children’s Health Insurance Program (WVCHIP) has temporarily implemented the following policies in response to COVID-19 being declared a pandemic by the World Health Organization and the related Governor’s declared State of Emergency. These policies are effective until the State of Emergency is terminated.
Current State of Emergency Policies for Providers, Including Telehealth, COVID-19 Testing, CoPayments, Prior Authorizations, Prescriptions, Premiums, and other Information. (UPDATE: Prescription CoPays Reinstated June 15, 2020)
Transition of Utilization Management and Prior Authorization
WVCHIP transitioned their utilization management (UM) contractor from HealthSmart to KEPRO on July 1, 2019.
Read letter to providers for more information.
Chip Providers - Provisional Provider Enrollment
Since June 30, 2016, all providers must be fully enrolled with CHIP to have your claims processed and paid. Call Gainwell Technology at
1-888-483-0793 with questions or to confirm you are fully enrolled, or to find out about enrolling.
WVCHIP Provisional Provider Enrollment Letter
WVCHIP Provider Enrollment
CHIP Provider Agreement
Provider Payment/Reimbursement Information
Health care providers are reimbursed according to the maximum schedule and rates established by WVCHIP. If a provider’s charge is higher than the WVCHIP maximum fee for a particular service, the Plan will only allow the maximum fee. The “allowed charge” for a particular service will be the lesser of either the provider’s charge or the WVCHIP maximum fee. Physicians and other health care professionals are paid accordingly to a Resource Based Relative Value Scale (RBRVS) fee schedule.
WVCHIP uses the Public Employees Insurance Agency’s fee schedules.
The following links will provide you with the current in-state fee schedules that are utilized by WVCHIP:
RBRVS Fee Schedule (January 2021)
Ambulance Fee Schedule (2021)
Air Ambulance Fee Schedule (1-1-19)
ASC Fee Schedule (2021)
Casts and Splints Fee Schedule (1-1-15)
Clinical Lab Fee Schedule (2021)
Critical Care Access Hospitals Fee Schedule (4-12-21)
Dental Fee Schedule (2021)
Dialysis Fee Schedule (1-1-15)
Drugs and Biologicals Fee Schedule (2021)
Durable Medical Equipment Fee Schedule (2021)
Ground Ambulance Fee Schedule (2-19-14)
Home Health Care Rates (1-1-15)
Home Infusion Therapy Fee Schedule (1-1-06)
Hospice Reimbursement Rates (2018)
Electronic Claims Submission
Providers should go to Gainwell Technologies Medicaid Managed Care website for more information
Reimbursement for Developmental Screenings in Pre-School Children
Effective March 1, 2014
WVCHIP believes that support for the Bright Futures guidelines, through its reimbursement and audit processes, is of fundamental importance to the well-being of pre-school children, particularly those in lower income households who are at high risk of undetected delays or disorders.
Therapy Services for Autism Spectrum Disorder
WVCHIP now covers Applied Behavior Analysis therapy services for children with a primary diagnosis of Autism Spectrum Disorder.
Antipsychotics Guidelines for Children
Provider Prescribing Guidelines for Antipsychotics
Antipsychotics for Children Prior Authorization Form
Dental Provider Guide
WV Dental Providers List
Dental Provider Dental Information Sheet
(See Dental Provider Guide above)
Dental Procedure Codes
Dental Benefit Forms
Orthodontic Treatment Precertification Form
What is Healthcheck? HealthCheck is the name of West Virginia's Early and Periodic Screening, Diagnosis and Treatment Program (E.P.S.D.T.). It is a program designed to ensure that eligible children under age 21 receive a comprehensive range of preventive and primary health services. This program provides periodic, comprehensive health examinations; vision, dental and hearing assessments; immunizations; and treatment follow-up of conditions found through the health examination. To obtain more detailed information, visit the HealthCheck Program's website by clicking the following:
For HealthCheck forms, go to the following link:
KEPRO provides medical case managment services to WVCHIP members experiencing a serious or long-term illness or injury. To contact KEPRO, call
visit their website.
Pre-Service Decisions: Prior Approval /Precertification Process
WVCHIP requires that certain services and/or items be reviewed in advance of service to determine whether they are medically necessary and are being provided in the most appropriat setting by an enrolled provider.
Prior Approval Form for Out of State / Out of Network Services
Requests for prior authorization should be submitted to the contracted utilization management organization, as early as possible in advance of the service/item.
Precertification is performed to determine if the admission/service is medically necessary and appropriate based on the member’s medical documentation, such as x-rays, diagnosis, tests, etc., made available by the member’s medical provider, and to evaluate the necessity for case management.
Failure to precertify or notify KEPRO of an admission or service within the timeframes specified may result in families being financially responsible for amounts above and beyond their copayment requirements.
Note: Prior Authorization
DOES NOT assure eligibility or payment of benefits under this Plan.
Prescription Drug Plan
WVCHIP provides its members with prescription drug benefits. Prescription drug benefits are administered by Express Scripts, Inc. (ESI). Enrolling a child in the Plan automatically enrolls them in the prescription drug plan.
Prior Authorization Process for Prescription Drugs
Several classes of prescription drugs require prior authorization for coverage by WVCHIP. The prior authorization process will involve the child’s physician and pharmacist communicating with WVU’s School of Pharmacy,"Rational Drug Therapy (RDTP) Program about the situation, since these prior approvals are given on a case-by-case basis. The child's doctor must call RDTP. If your medication is not approved for plan coverage, you will have to pay the full cost of the drug. WVCHIP will cover, and your pharmacist can dispense, up to a five-day supply of a medication requiring prior authorization for the applicable copayment. This policy applies when your doctor is either unavailable or temporarily unable to complete the prior authorization process promptly.
The following link is for providers who want to print out the Prior Authorization Form to submit to the Rational Drug Therapy Program:
Prior Approval Request Form.
Prior Approval for Medicine for Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder
Prior Authorization Policy - Therapeutic Guidelines
WVCHIP has added stimulants, amphetamines and atomoxetine to the list of medications that need prior approval through the Rational Drug Therapy Program (RDTP). The goals of this therapeutic guideline policy is to promote overall disease management such that medication treatment is supported by adjunctive psychosocial programs, ample patient contact, and frequent follow-up visits throughout the course of therapy to address non-medication treatment alternatives, comorbid disorders, dosage titration, adverse effects, and drug diversion and misuse.
In order to simplify the process for the providers, we have revised an RDTP prior approval form and changed it to specifically address the ADHD/ADD prior approval process.
Prior Approval Request Form for Attention Deficit Disorder Medication
Rational Drug Therapy Program Now Reviews Prior Authorization Drug Requests
Those who were already established on these medications prior to August 1, 2009, may continue to receive these medications, however, prior authorization must be renewed annually.
New Preferred Drug List for WVCHIP Members
The West Virginia Children’s Health Insurance Program updates the Preferred Drug List (PDL), annually. Click here for the
WVCHIP Preferred Drug List.
Non-preferred drugs will not be covered. If a provider chooses to prescribe a drug not listed on the Preferred Drug List (PDL), it will be a 100% retail cost to the patient. Co-payments for drugs on the new PDL will remain the same. Questions concerning drugs covered by WVCHIP should be directed to Express Scripts, Inc. at
Common Specialty Medications
All specialty medications require prior authorization. The process begins with a call to Express Scripts, Inc. (ESI) at
1-855-230-7778. ESI will review the drug for medical necessity, and if approved, will coordinate he purchase through an approved source. Specialty drugs have the following key characteristics:
- Need frequent dosage adjustments
- Cause more severe side effects than traditional drugs
- Need special storage, handling and/or administration
- Have a narrow terapeutic range
- Require periodic laboratory or diagnostic testing
- New Member Cards
The WVCHIP plan is governed in part by the Omnibus Health Care Act enacted by the West Virginia Legislature in April 1989. This law requires that any health care provider who treats a WVCHIP benefit plan cardholder must accept assignment of benefits. Plan cardholders cannot be billed for any balance of charges over and above the WVCHIP fee allowance or any discount amount applied to the provider’s charge or payment.
Frequently Asked Questions
Q. How does my office verify CHIP eligibility?
A. By calling our toll-free helpline at
1-877-WVA-CHIP for eligibility verification on the date of service remains our best eligibility verification mechanism at present.
www.wvmmis.com. Contact Gainwell Technologies at
1-888-483-0793 for more information.
Q. How does my office file a medical claim for a WVCHIP patient?
A. Providers must use the standard CMS (Formerly HCFA) 1500 Claim Form to request reimbursement for services. Claims may be mailed or submitted throught the provider portal. See the Gainwell Technologies Medicaid Managed Care website,
www.wvmmis.com for more information.
Q. What does my office need to do if we dispute a reimbursement claim?
A. Providers are requested to first fully review any disputed claims amount or denial with Gainwell Technologies, the claims administrator, at
1-888-483-0793. Any provider still wishing to dispute the amount or denial of reimbursement may file an appeal in writing to:
Executive Director, WVCHIP
350 Capitol Street
Charleston, WV 25301
WVCHIP@wv.gov with "Appeal" in the subject line
For claim appeals, out-of-state, claims management, incorrect payment, timely filing and dental claims, appeal in writing to Gainwell Technologies. An appeal may also be submitted through the provider portal at
wvmmis.com. For pharmacy claims, appeal in writing to:
ATTN: Commercial Claims
PO Box 14711
Lexington, KY 40512-4711
Q. Do WVCHIP members have copayments for medical services?
A. Yes, some plan members have copayments for certain medical and prescription services. Click here for
Q. Does my office have to precertify any medical services for a WVCHIP patient?
A. Yes. Providers must contact KEPRO at
1-888-571-0262. For list of Inpatient, Outpatient and Specialized Services see
Summary Plan Description
*If the admission is an emergency, then a parent, guardian, family member, provider or other designated person must call KEPRO within 48 hours of the admission.
Q. Who Do I Call About Prescription Drug Coverage?
A. Contact Express Scripts at
1-855-230-7778 or visit them online at Express-Scripts.com. Click here for the
WVCHIP Preferred Drug List.
Q. Who do I call to preauthorize prescription drug coverage?
A. Contact WVU's Rational Drug Therapy Program at
For more information about benefits, please review the
Summary Plan Description. Click here to view WVCHIP's
Notice of Privacy Practices.
Informational Resources Helpful To Providers