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Provider Resources

New Outpatient Therapy Guidelines

Physical and Occupational Therapy Guidelines
Speech Therapy Guidelines
Vision Therapy Guidelines

Prior Approval/Prior Authorization Forms

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

Medical Home Program 

Medical Home Selection Form (for members)

Prescription Drug Plan

Current Preferred Drug List 
CVS Caremark Prescription Reimbursement Claim Form
Prior Approval Request for Prescriptions
Prior Approval Request Form for ADD Medications
Prior Approval Request Form for Antipsychotics Medications, and Guidelines

Immunization Resources

CPT Codes for Immunizations
Immunization Schedule for Ages 0-6 years
Immunization Schedule for Ages 7-18 years

Preventative Care

Dental Care Flyer
Vision Care Flyer
Well-Child Exam Flyer
Child Development Flyer
Hearing Screening Flyer

Healthcheck Forms

Healthcheck Provider Manual and Forms

Dental Information

Dental Provider Guide

Benefit Resources & Reimbursement

Reimbursement for Developmental Screenings

Applied Behavioral Analysis

Policy: Applied Behavior Analysis  (Effective January 2019)
2019 Applied Behavior Analysis Allowable Services and Coding Guide
Minimum Training Standards: Front Line ABA Staff

Providers who need to submit Prior Authorization requests for ABA services for a WVCHIP member should go to http://wvaso.kepro.com to complete your request electronically.  If you experience any problems with your submission, please contact KEPRO at 1-888-571-0262.

Required Documents for Pre-Authorization Requests

Applied Behavior Analysis (ABA) Services Pre-Authorization Request Form (Cover Sheet to PA Request)
Applied Behavior Analysis (ABA) Prior Authorization Units of Service Request Form
ABA Statement of Assurance