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 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.
Ambulance Fee Schedule (1/1/19)
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)
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 Provider Guide
WV Dental Providers List
Dental Provider Dental Information Sheet
(See Dental Provider Guide above)
Dental Procedure Codes
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
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
KEPRO provides medical case managment services to WVCHIP members experiencing a serious or long-term illness or injury. To contact KEPRO, call 1-888-571-0262, or 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 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
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 CVS/Caremark at 1-866-814-5506. CVS 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
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.
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.
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:
Executive Director, WVCHIP
350 Capitol Street
Charleston, WV 25301
Email: 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 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 KEPRO at 1-888-571-0262. 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 KEPRO within 48 hours of the admission.
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.