For Providers to begin providing services to a child who has health coverage through WVCHIP, they should contact WVCHIP's third party administrator, HealthSmart, to obtain the few forms they would need to fill out to get reimbursed. They only need to accept the reimbursement amount provided by WVCHIP. To see more information about Provider Payment-Reimbursement information, click here.
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.
You can also go to this page to print out the list: WVCHIP In-State Fee Schedules
Air Ambulance Fee Schedule (2-20-14)
ASC Fee Schedule (7-1-14)
Casts and Splints Fee Schedule (1-1-15)
Clinical Lab Fee Schedule (1-1-15)
Dental Fee Schedule (3-15-13)
Dialysis Fee Schedule (7-1-05)
Drugs and Biologicals Fee Schedule (1-1-15)
Durable Medical Equipment Fee Schedule (1-1-15)
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 (1-1-15)
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 Funds Transfer
Providers must complete forms to authorize payment by Electronic Funds Transfer. See HealthSmart's website (Forms Download page) for more information. Click here for the form to sign up for Electronic Funds Transfer.
If you have questions regarding the Electronic Funds Transfer process, please contact HealthSmart, at 1-800-356-2392.
Electronic Claims Submission
Providers may bill WVCHIP electronically through HealthSmart using several services. Click here for more information on accessing claim and eligibility information online. You can check claim status and verify eligibility online at HealthSmart's website. Read more for instructions. Click here for more information.
Reimbersement 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.
New Covered Benefits Announcement: Therapy Services for Autism Spectrum Disorder.
WVCHIP now covers Applied Behavior Analysis therapy services for children with a primary diagnosis of Autism Spectrum Disorder.
Fact Sheet on WVCHIP Plan Coverage for Autism Spectrum Disorder
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".
Provider Signup Form
Medical Home Directory of Providers (those who have signed up)
Medical Home Directory: Primary Care Providers
In case your office is asked 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 mandated Medicaid Program enacted in 1967 to ensure that Medicaid-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
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
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, to be prior approved. This requirement applies to both network and non-network providers.
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 ActiveHealth 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 Express Scripts, Inc. (ESI). 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.
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 Express Scripts, Inc. (ESI) at 1-877-256-4689.
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.
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.
HealthSmart 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.healthsmart.com. Also, HealthSmart's fax back service allows the provider to bypass speaking to a customer service representative when calling to verify eligibility and copayments. Contact HealthSmart at 1-800-356-2392 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 for all medical, dental and vision services should be forwarded to:
PO Box 2451
Charleston, WV 25329-2451
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 HealthSmart, the claims administrator, at 1-800-356-2392. 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 HealthSmart, PO Box 2451, Charleston, WV 25329, and for pharmacy claims, appeal in writing to Express Scripts, Inc., PO Box 390873, Bloomington, MN 55439.
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 Express Scripts, Inc. at 1-877-256-4680 or visit them online at ExpressScripts.com. 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 Plan. 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.