| Providers
do not have to be a “member”
of WVCHIP to provide services
to a child who has health
coverage through CHIP. They
only need to accept the reimbursement amount
provided by CHIP.
WV CHIP Dental Providers List
http://www.insurekidsnow.gov/state/westvirginia/index.html
Prior Approval Description and Required 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, 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:
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 Active Health 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 for services
Medical Home Program (Provider Signup Form)
Medical_Home_Provider_Application
ActiveHealth
ActiveHealth Management provides utilization and care management services to West Virginia Children's Health Insurance Program (WVCHIP) membrs. Effective July 1, 2009, ActiveHealth will assume responsibility for all preservice decisions. ActiveHealth also provides medical case managment services to WVCHIP membrs experiencing a serious or long-term illness or injury. To contact ActiveHealth call 1-800-356-2392.
New WVCHIP 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.
Prior Approval Form for Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder.
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 ADD/ADHD prior approval process.
Prior Approval Request Form for Attention Deficit Disorder Medication (082009)
Prior Authorization Policy - Therapeutic Guideline (07/01/2009)
WV Health Check Form for Children's Check Ups and Entrance into School
HealthCheck for all West Virginia Children
New Preferred Drug List for WVCHIP members
The West Virginia Children’s Health Insurance Program has updated the Preferred Drug List (PDL), effective January 1, 2010. Click here for the new 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. (ESI) at 1-877-256-4689.
Reimbursement
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.
Providers can check the PEIA
website at www.wvpeia.com
for specific procedure codes
covered under the WVCHIP Plan.
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.
Treasurer's Office Now Writes WVCHIP Checks.
Click here for more information.
Electronic Claims Submission
Providers may bill WVCHIP electronically through Well's Fargo using several services.
Click here for more information.
Accessing Claim and Eligibility Information Online
You can check claim status and verify eligibility online at Well's Fargo website. Read more for instructions.
Click here for more information.
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 already on these medications may continue; however any new prescription for children under six (6) must be prior authorized, effective August 1, 2009.
Common Specialty Medications
Beginning July 1, 2005, WVCHIP selected CuraScript as the exclusive pharmacy for Common Specialty Medications. Click here for more information.
How does my office
verify CHIP eligibility?
How does my office
file a medical claim for a
WVCHIP patient?
What does my
office need to do if we dispute
a reimbursement claim?
Do WVCHIP members
have copayments for medical
services?
Does my office
have to precertify any medical
services for a WVCHIP patient?
What do I need
to do if I have to send a
CHIP patient out of state
for a medical procedure?
Who do I call
about prescription drug coverage?
What’s
New to WVCHIP?
How can my office
promote WVCHIP?
Who do I call to preauthorize prescription drug coverage?
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.
Well's Fargo 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.wellsfargo.com/tpa.
Also, Well's Fargo’s
fax back service allows the
provider to bypass speaking
to a customer service representative
when calling to verify eligibility
and copayments. Contact Well's Fargo 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:
Well's Fargo
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 Well's Fargo,
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, and claims management, appeal in writing to ActiveHealth Management, PO Box 221138, Chantilly, VA 20153; for incorrect payment, timely filing and dental claims, appeal in writing to Wells Fargo TPA, 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
ActiveHealth at 1-800-356-2392. For list of Inpatient, Outpatient and Specialized Services see Summary Plan Description (SPD), pages 17-18.
*If the admission is an emergency,
then a parent, guardian, family
member, provider or other
designated person must call
ActiveHealth at 1-800-356-2392
within 48 hours of the admission..... Remember,
for out-of-state care, the
parent or guardian must contact
ActiveHealth 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. The Aetna Signature Administrators (ASA) Preferred Provider Organization (PPO) is WV CHIP's out-of-state network. Cardholders using an out-of-state provider
must get prior approval
from ActiveHealth to ensure that
their claim will be paid.
Should they need assistance
locating a network provider,
they can call Well's Fargo
at 1-800-356-2392. If they
have access to the Internet,
provider information can be
obtained by visiting the
website: www.aetna.com/docfind/custom/asa.
Q. Who Do I Call About
Prescription Drug Coverage?
A. Contact Express Scripts,
Inc. at 1-877-256-4680 or
visit them online at
www.express-scripts.com.
Click here for the latest
drug
formulary.
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 and Provider
Guide. Click here to view WVCHIP's Notice of Privacy Practices.
Provider Outreach
As a provider you see patients
everyday with out 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
an outreach
order form to start your
outreach efforts today.
Provider Publications
Provider Guide
Preferred Drug List
CPT Codes for Immunizations
Immunization Schedule for Ages 0-6 years
Immunization Schedule for Ages 7-18 years
Dental Care Flyer
Vision Care Flyer
Well-Child Exam Flyer
Child Development Flyer
Hearing Screening Flyer
Healthcheck Forms
Kindergarten Screening Document
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