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Transition of Utilization Management and Prior Authorization

WVCHIP is transitioning 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 DXC 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 Education

The Centers for Medicare & Medicaid Services (CMS) will host four Payment Error Rate Measurement (PERM) provider education sessions during FY 2016. The purpose is to provide opportunities for the providers of the Medicaid and Children’s Health Insurance Program (CHIP) communities to enhance their understanding of specific provider responsibilities during the PERM cycle. ​​​​​​​​​​​​​​​

For More Information.....​​

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.  

Air Ambulance Fee Schedule (1-1-19)
ASC Fee Schedule (7-1-14)
Casts and Splints Fee Schedule (1-1-15)
Clinical Lab Fee Schedule (1-1-19)
Critical Care Access Hospitals Fee Schedule (4-19-19)
Dental Fee Schedule (2019)
Dialysis Fee Schedule (1-1-15)
Drugs and Biologicals Fee Schedule (1-1-19)
Durable Medical Equipment Fee Schedule (1-1-19)
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 (7-6-11)
RBRVS Fee Schedule (3-7-19)

WVCHIP has a blanket Prior Authorization on services provided outside the state of West Virginia.  Primary care, in bordering counties, and emergency services are excluded.  The process evaluates whether services provided out of state are available in-state within a geographic accessible area to the member.  WVCHIP will waive this requirement for all out of state providers who agree to accept in-state rates as payment in full.  Services that would otherwise require Prior Authorization regardless of in-state or out of state will still apply. Providers must also agree to not balance bill WVCHIP members for the difference between submitted charges for covered services and WVCHIP's fees.   

Electronic Claims Submission

Providers should go to DXC Technology's Medicaid Managed Care website for more information http://www.wvmmis.com. 

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.  

Dental Services 

Dental Provider Guide   "newly updated"
WV Dental Providers List
Dental Provider Dental Information Sheet (See Dental Provider Guide above)
Dental Procedure Codes


Dental Benefits

Orthodontic Treatment Precertification Form


Medical Home Program

To see the information given to WVCHIP families in the Summary Plan Description on the Medical Home Program, click the following title: "The Importance of a Medical Home".
The Medical Home Directory of Providers (those who have signed up) can be viewed at www.wvmmis.com.  You can also call DXC Technology at 1-800-479-3310 for a directory.

In case your office is asked by a member for a form to sign up for the Medical Home Program
Medical Home Selection Form 

WV HealthCheck

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:    HealthCheck Program.

For HealthCheck forms, go to the following link:
  HealthCheck Forms

Case Management

HealthSmart provides medical case managment services to WVCHIP members experiencing a serious or long-term illness or injury.  To contact HealthSmart, call 1-800-356-2392, or visit their website.

Pre-Service Decisions: Prior Approval /Precertification Process


Prior Approval

WVCHIP requires ALL services outside the State of West Virginia, except office visits to primary care doctors in counties bordering West Virginia in surrounding states, emergency services or services by providers who have accepted WVCHIP in-state rates, to be prior approved. 

Failure to obtain prior approval for out-of-state services may result in the member or member’s family being responsible for the difference between the provider’s charges and WVCHIP’s allowed amounts, or for the entire cost of the claim.  Charges in excess of WVCHIP’s allowed amounts are considered non-covered services.

Prior Approval Form for Out of State / Out of Network Services


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 HealthSmart 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: Precertification DOES NOT assure eligibility or payment of benefits under this Plan.

Precertification Form for Services

Prescription Drug Plan

WVCHIP provides its members with prescription drug benefits. Prescription drug benefits are administered by CVS/Caremark.  Enrolling a child in the Plan atutomatically enrolls them in the prescription drug plan.

Drugs Requiring Prior Authorization

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

Please note that four medications now require Prior Authorization through RDTP for children under the age of six with diagnosis of ADHD.  These medications are:  Adderall XR, Concerta, Ritalin, and Strattera.  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.

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


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 current WVCHIP Preferred Drug Formulary.

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 CVS/Caremark at 1-800-241-3260.

Common Specialty Medications

All specialty medications require prior authorization.  The process begins with a call to HealthSmart at 1-800-356-2392, Option 7.  HealthSmart will review the drug for medical necessity, and if approved, will coordinate the 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

If you are prescribed one of these common specialty medications, call HealthSmart at 1-800-356-2392, Option 7.

New Member Cards

Cards have been renamed WVCHIP Gold; WVCHIP Blue, and WVCHIP Premium.  These cards have the medical benefits and prescription benefits listed on the back of the cards.

Providers can submit claims using either the ID number or the social security number.  Both the medical and the prescription drug claim systems can accept either identifier. 

Click here  to see Examples of the Member Cards for the three levels of WVCHIP:  Gold, Blue and Premium.  Also a copy of the WVCHIP Exempt card is available for review.  Federal regulations exempt Native Americans/Alaskans from cost sharing.  This exemption can be claimed by calling 1-877-982-2447 to declare tribal designation and confirm that it is listed as a federally recognized tribe.

Anyone who has not received their card and has WVCHIP coverage can call DXC Technology at 1-800-479-3310 to receive a card.

Prohibition of Balance Billing

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.


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.

DXC Technology is an additional resource that providers can use to check the status of a claim and verify eligibility. Each provider will self-register online for this service on their website at www.wvmmis.com.  Contact DXC Technology 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 DXC Technology 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 DXC Technology, 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:

For claim appeals, out-of-state, claims management, incorrect payment, timely filing and dental claims, appeal in writing to Molina.  An appeal may also be submitted throught the provider protal at wvmmis.com.  For pharmacy claims, appeal in writing to:

Clinical Appeals (Client-WVC) 
PO Box 52136
Phoenix, AZ  85072-2136

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 copayment information.

Q. Does my office have to precertify any medical services for a WVCHIP patient?

A. Yes. Providers must contact HealthSmart at 1-800-356-2392. For list of Inpatient, Outpatient and Specialized Services see Summary Plan Description (SPD).

*If the admission is an emergency, then a parent, guardian, family member, provider or other designated person must call HealthSmart at 1-800-356-2392 within 48 hours of the admission..... Remember, for out-of-state care, the parent or guardian must contact HealthSmart for prior approval.

Q. What do I need to do if I have to send a WVCHIP patient out of state for a medical procedure?

A.  HealthSmart is WV CHIP's out-of-state network.  Cardholders using an out-of-state provider must precertify services with HealthSmart Care Management Solutions to ensure that their claim will be paid. Should they need assistance locating a network provider, they can call HealthSmart at 1-800-356-2392. If they have access to the Internet, provider information can be obtained by visiting the website: www.healthsmart.com.

Q. Who Do I Call About Prescription Drug Coverage?

A. Contact CVS/Caremark at 1-800-241-3260 or visit them online at CVS/Caremark.  Click here for the current WVCHIP Preferred Drug List.

Q. Who do I call to preauthorize prescription drug coverage?

A. Contact WVU's Rational Drug Therapy Program at 1-800-847-3859.

For more information about benefits, please review the Summary Plan Description.  Click here to view WVCHIP's Notice of Privacy Practices.

Displaying WVCHIP Informational Materials

As a provider you see patients everyday without health care. You can help promote WVCHIP by having materials available in your waiting area and counseling patients about insurance opportunities during an office visit. Complete a WVCHIP Literature Order Form to request informational materials for displaying in your office waiting room.

Informational Resources Helpful To Providers