Announcements & Newsletters

The ProviderFocus Newsletter is your quarterly update on what’s new with The Health Plan. In each issue, you’ll learn about updates to practice guidelines, important deadlines, educational opportunities and more!

Browse our past and current newsletters:



Introducing THP's New Chief Medical Officer (CMO)

We are excited to announce the appointment of Dr. Mumtaz Ibrahim, M.D., as our new Chief Medical Officer (CMO) at The Health Plan. 

Dr. Ibrahim is a seasoned healthcare executive with over twenty years of success maximizing member outcomes, compliance, data-driven programs, operational efficiency, and gross margins across healthcare entities. His skillsets span medical and population health management, clinical operations, risk adjustment, quality improvement, and more. 

Click here to see the full announcement

Change Healthcare Cyberattack Follow-up

Effective March 14, 2024, The Health Plan (THP) restored electronic claims
(EDI 837 I and 837 P) connectivity through Optum iEDI 

What does this announcement mean for physicians, hospitals and ancillary providers submitting electronic claims?
THP’s payer ID remains 95677 for 837 I and 837 P claims.
If your organization submits EDI claims through a clearinghouse other than Change Healthcare: 


  • THP confirmed Optum iEDI is connected with Availity, Quadax, SSI, Trizetto, and Waystar; if your organization submits through another EDI clearinghouse, please contact them to confirm they are connected with Optum iEDI, and if not, please ask them to establish a connection.
  • Electronic claims submitted to your EDI clearinghouse on or after February 21, 2024 are expected to process automatically. 
  • Please resubmit electronic claims ONLY if your organization did not receive an acknowledgment/response file.

If your organization submits EDI claims through Change Healthcare’s clearinghouse:

  • Change Healthcare’s EDI is not yet available, therefore, a connection to another claims EDI clearinghouse is required to submit electronic claims.
  • Please submit electronic claims to your new EDI clearinghouse ONLY if your organization did not receive an acknowledgment/response file.

What does this announcement mean for THP? 

Finance will add an additional check / EFT run.  Check / EFT runs will be:

  • Week of March 18 (scheduled)
  • Week of March 25 (added due to Change Healthcare cyberattack)
  • Week of April 1 (scheduled) 

Finance will assess if another check / EFT run needs added the week of April 8.
Information Technology will continue to work with Optum to re-establish Electronic Remittance Advice (ERA / EDI 835) availability.  THP makes payment voucher available through its MyPlan Provider Portal; please contact your Practice Management Consultant if you need assistance with MyPlan Provider Portal.

Change Healthcare Cyber Security Attack FAQs

As recently communicated, on February 21, 2024, Change Healthcare, a health care technology company that is a part of Optum and owned by UnitedHealth Group, announced they were compromised by a cyberattack that disrupted a number of its systems and services, according to a statement posted on its website.

THP continues to monitor the Optum/Change Healthcare issue closely and developed FAQs to help answer your questions.

THP will share more information as it becomes available. If there are additional questions about how Change Healthcare's cyberattack situation impacts you and your healthcare organization, please contact your THP Practice Management Consultant.

WV Medicaid Program Copay Reimplementation

Effective May 12, 2023, The Health Plan has reimplemented copays for WV Medicaid members. Based on guidance from the WV Bureau for Medical Services (BMS) and Centers for Medicare and Medicaid Services (CMS), you have the right to begin immediate collection of copays for qualifying services. This transition is the result of the official end of the federal COVID-19 Public Health Emergency declaration which expired as of May 11, 2023. Providers may collect copays for the following qualifying services:

Inpatient Hospital (Acute Care)
Office Visit (Physicians and Nurse Practitioners) 
Non-Emergency Use of the Emergency Department
Any outpatient surgical services rendered in a physician's office, ASC or outpatient hospital, excluding Emergency Rooms

Please note that copays for the WV Children’s Health Insurance Program (WVCHIP) will resume as of effective July 1, 2023. Copays for this program should not be collected prior to that date. 

Notice to all Enrolled Ambulance Providers

Effective immediately, codes A0998 HF (EMS administering Naloxone) and H0050 HF (Warm handoff of patient to provider) are to be billed to Gainwell (MMIS for WV BMS) for managed care members. These services are considered to be “carved out” of the managed care contract and shall be reimbursed by the State. Providers should continue to bill The Health Plan for A0998 with no modifier or with modifiers other than HF.

Providers may contact THP Customer Service at 1.888.613.8385, Monday-Friday, 8am-5pm EST, with any questions.

Medicaid Targeted Case Management Adult Eligibility and Service Guiderails

The Health Plan supports care management as an evidence-based method for integrating behavioral health and medical care. However, West Virginia Medicaid Targeted Case Management has clearly specified “guiderails” for eligibility and service. 

Click here for more information on Medicaid Targeted Case Management Adult Eligibility and Service Guiderails.

Claim Denial Codes for Out-of-Network Providers in Compliance with the No Surprises Act

The No Surprises Act became effective on January 1, 2022. This legislation provides financial protection to members against surprise medical bills and prohibits balance billing for certain out-of-network (OON) care.

The Health Plan (THP) has incorporated the Health Insurance Portability and Accountability Act (HIPAA) compliant denial codes below for claims submitted to THP by OON providers.

The following Claim Adjustment Reason Code (CARC) will appear on claims submitted by an OON provider:

  • 242 - Services not provided by network/primary care providers

In addition to the CARC code above, one (or more) of the Remittance Advice Remark Code(s) (RARC) below will also appear on the provider’s payment voucher:

  • N830 Alert: The charge(s) for this service was/were processed in accordance with Federal/ State Balance/Surprise Billing regulations. As such, any amount identified with OA, CO, or PI cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer. Any amount the provider collected over the identified patient responsibility amount must be refunded to the patient within applicable Federal/State timeframes. Payment amounts are eligible for dispute following any Federal/State documented. appeal/grievance/arbitration process.
  • N859 Alert: The Federal No Surprise Billing Act was applied to the processing of this claim. Payment amounts are eligible for dispute following the Federal documented appeal/grievance/dispute resolution process.
  • N860 Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).

THP Expands Partnership with eviCore Healthcare

The Health Plan (THP) is pleased to expand its ongoing partnershiwiteviCore healthcare to provide medicalnecessity review and authorization for members receiving services for the following that were previously provided through Palladian Health:


Musculoskeletal (MSK) 

  • Specialized Outpatient Therapies
    • PT and OT
    • Chiropractic Care
  • Pain Management

Additionally, eviCore healthcare will begin to review and authorize:

  • Joint and Spine Surgery

These changes will become effective on December 13, 2021 for dates of service beginning January 1, 2022 andwill affect THP members belonging to the following lines of business:

  • Commercially insured fully-funded plans (including HMO, PPO, POS, and WV PEIA plans)
  • THP Mountain Health Trust (Medicaid and WVCHIP) 
  • Medicare (including SecureCare HMO, SecureChoice PPO, and Dual Eligible Special Needs Plans)

Services performed without authorization may be denied for payment, and you may not seek reimbursement frommembers.


eviCore will be providing provider orientation sessions via WebEx. Pleasgto their website here and click on the “Upcoming” tab to register for one of the followinWeb-Ex sessions:

  • THP MSK therapy and chiro
  • THP MSK pain, joint and spine


Webinar Options




THP MSK therapy and chiro


Dec. 6, 2021

1:00 – 2:00 PM EST

THP MSK pain, joint and spine


Dec. 8, 2021

10:00 –11:00 AEST

THP MSK therapy and chiro


Dec. 9, 2021

1:00 – 2:00 PM EST

THP MSK pain, joint and spine

Dec. 16, 2021

10:30 – 11:30 AM EST

THP MSK therapy and chiro


Jan. 4, 2022

1:00 – 2:00 PM EST

THP MSK pain, joint and spine

Jan. 5, 2022

3:30 – 4:30 PM EST


Drug Screening in Outpatient Substance Use Disorder Populations

The Health Plan (THP) works hard to responsibly manage available health resources while promoting best practices and adherence to governmental regulation.

THP has approved point of care testing with oral fluids billed as 80305. THP recommends random point of care screening for illicit or inappropriate substance use for programs providing outpatient pain management and substance use disorder services, using either oral fluids or urine. Occasionally confirmatory drug testing will be necessary, particularly under the following conditions:

  1. The member appears intoxicated or impaired but point of care testing is negative;

  2. Results of point of care/presumptive testing yield unexpected results (possibly due to

    metabolites from other medications or OTC products resulting in false positives);

  3. The member is negative for the prescribed substance(s) but denies diversion;

  4. The member is positive for illicit substances but denies use when confronted; and

  5. There is evidence that the sample was adulterated or altered in any way.

However, routine confirmatory testing is not recommended and could be viewed as overbilling, particularly if the clinician cannot justify the testing in his/her documentation.

The American Society of Addiction Medicine guidelines for drug screening, summarized in “Appropriate Use of Drug Testing in Clinical Addiction Medicine,” make the following recommendations:

Test Frequency: For people in addiction treatment, frequency of testing should be dictated by patient acuity and level of care. Providers should examine a test’s detection capabilities and windows of detection to determine the frequency of testing. Providers should understand that increasing the frequency of testing increases the likelihood of detection of substance use, but there is insufficient evidence that increasing the frequency of drug testing affects substance use itself.

  • Drug testing should be scheduled more frequently at the beginning of treatment.

  • Test frequency should be decreased as recovery progresses.

  • When possible, testing should occur on a random schedule.

  • Individual consideration may be given for less frequent testing if a patient is in stable recovery.

Random Testing: Unannounced drug tests are preferred to scheduled drug tests. A random-interval schedule is preferable to a fixed-interval schedule because it eliminates known non-testing periods (eg, if Monday is randomly selected from a week interval, the patient knows they will not be tested Tuesday-Saturday) and it is preferable to a truly random schedule because it limits the maximum number of days between tests.

Superior Vision Partnership

The Health Plan is pleased to announce that effective July 1, 2021 Versant Health/Superior Vision will become the new vision partner of The Health Plan for our Commercial lines of business. There is no change to our Medicare, Mountain Health Trust or ASO products.

Important Information Regarding WV Medicaid's Adult Dental Benefit


Effective April 1, 2021, The Health Plan (THP) will transition both the adult emergent dental benefit and the adult preventive $1,000 benefit for WV Medicaid members to Skygen USA.  This transition will align the administration of dental services with those for Medicaid and WVCHIP members under age 21. 

Providers will need to submit claims, authorization requests and pre-treatment estimates to Skygen as of the April 1 date. 

WV Medicaid Adult Dental Benefit (Emergent and $1,000 Preventive/Restorative)

Claims should be submitted on ADA claim form 2012 or newer.
Claims are to be submitted to:
West Virginia Claims
PO Box, 795
Milwaukee, WI, 53201

Provider Services:


Clearinghouse Information (Payer ID: SCION)

Change Healthcare

(formerly Emdeon)

*Also contracted for attachment services


(formerly EHG)

*Also contracted for attachment services

Vyne Dental

(dba Tesia Clearinghouse)

*Providers can use Fast Attach™


*Providers can use Fast Attach™ for attachment services  
1-866-371-9066 1-800-576-6412 1-800-724-7240 1-855-297-4436

Please contact us if you have any questions at 1.888.613.8385. Adult members age 21 and older will receive new cards with the Skygen information listed on it on or about April 1.

The Health Plan Collaborating with Health Management Systems

Effective 10/30/2020 The Health Plan (THP) is contracting with Health Management Systems, Inc (HMS) to perform third party liability and related revenue recovery services. Medicaid is the payer of last resort by Federal statute (42 U.S.C. 1396a (25), 1396b (d) (2) and 1396b (O)). 

Contractual requirements with the Department of Health and Human Resources (DHHR) require recovery of payments made on identified claims for which other health insurance is primary.

Identification by HMS of members with other insurance policies will result in proper claims payments and recoveries.

Implementation of Hospital Claims Editing Software

Effective October 1, 2020, The Health Plan (THP) will be implementing ClaimsXten, a claims editing tool developed by McKesson Information Solutions. ClaimsXten rules are clinically based and validated by a national panel of clinicians and medical experts.

THP previously implemented this software for professional claims and is now incorporating hospital claims.

The hospital claims edits will be applied across all THP product lines, which currently include Commercial, Medicare Advantage, Public Employees Insurance Agency (PEIA) and West Virginia Medicaid lines of business.

Some examples of ClaimsXTen edits include:

  • Deleted code edits
  • Gender edits
  • Age edits
  • Pre-operative visit, same day visit, post-operative visit bundling edits
  • Frequency validation: once or multiple times per date edits
  • Bilateral procedure edits
  • Multiple code re-bundling, multiple surgery, and assistant surgeon edits
  • Unbundling, incidental, mutually exclusive edits
  • Medicare and Medicaid-related Correct Coding Initiative (CCI) logic
  • Other Centers for Medicare and Medicaid Services (CMS) carrier directives          

As a result of THP’s ClaimsXten claims editing software, hospital providers will receive less post-payment audits and recoveries.

Please contact THP at 1.800.624.6961 with questions.

THP Following CMS & BMS Guidelines

The Health Plan is following the temporary measures related to healthcare services instituted by the Centers for Medicare and Medicaid Services (CMS) and the Bureau for Medical Services (BMS) during the coronavirus (COVID-19) pandemic.

Please refer to CMS guidelines related to COVID-19 for our members with Commerical (including POS, PPO, HMO, & WV PEIA) and Medicare coverage. Those guidelines may be accessed here. BMS guidelines related to COVID-19 will be followed by The Health Plan for our Medicaid members. Self-funded plans default to the group plan document.

The Health Plan is also following CMS and BMS guidelines for telehealth services rendered during the COVID-19 pandemic. Bill the appropriate CPT/HCPCs code and use "02" for the Place of Service if billing on a HCFA 1500 form. For Medicaid members only, if billing on a UB04 form, bill the appropriate CPT/HCPCs code with the -GT modifier.

These are temporary measures due to the COVID-19 crisis and The Health Plan reserves the right to re-evaluate at a later date. Contact The Health Plan at 1.800.624.6961 if you have any questions or need further assistance.

eviCore healthcare Will Conduct Prior Authorizations

The Health Plan has partnered with eviCore healthcare to manage medical necessity review and prior authorization for Commercial, THP Medicaid and Medicare populations for radiology/cardiology, durable medical equipment and sleep studies

eviCore conducts medical necessity review and prior authorization for the Medicare population only for post-acute care that includes skilled nursing, home health, long-term acute care and inpatient rehab.

Changes to the Behavioral Health Prior Authorization List

Effective July 1, 2019, the following were added to the Behavioral Health Prior Authorization List:

Inpatient Care Addition

  • Residential Adult Services for Substance Use Disorder Waiver: ASAM Level 3.1(H2036U1HF), ASAM Level 3.3(H2036U3HF), ASAM Level 3.5 (H2036U5HF) and ASAM Level 3.7 (H2036U7HF)

Ambulatory Services Addition

  • Peer Recovery Support (H0038)

View the full Behavioral Health Prior Authorization Requirements List under Prior Authorization and Referrals.

PT/OT Services Now Managed by Palladian Health for Members with an Autism Diagnosis

Medical necessity review and prior authorization for physical therapy and/or occupational therapy services for members with an autism diagnosis will be managed by Palladian Health. Initial evaluations do not require prior authorization and members may self-refer for evaluation.

Medical necessity review and prior authorizations may be completed through The Health Plan's secure provider portal, MyPlan, by fax at 1.844.681.1205, or by phone at 1.877.244.8514. Questions on this new process may be addressed to The Health Plan at 1.877.847.7901 or by contacting your practice management consultants.

Introducing New Claim Editing Software

The Health Plan has implemented ClaimsXten, a new claims code editing software. Developed by Change Healthcare (previously McKesson) it is widely used throughout the healthcare industry by Medicaid managed care organizations, health insurers, and third-party administrators across the nation to improve payment accuracy, reduce appeals and realize medical and administrative savings.