WV Medicaid

The Health Plan is one of three managed care organizations approved by the Bureau for Medical Services (BMS) to provide services to West Virginia Medicaid recipients.

The Health Plan's Provider Manual contains comprehensive information related to best practices for the care of this population. 

Provider Reimbursements

The Health Plan follows the Bureau for Medical Services’ (BMS) guidelines pertaining to reimbursement for emergency room services rendered to Medicaid members.

Medicaid covers five levels of emergency room services. There are five CPT procedure codes available for billing emergency room services.

The enhanced reimbursement is an all-inclusive fee, which is considered to include the following items:

  • Use of emergency room
  • Routine supplies (such as sterile dressings)
  • Minor supplies (bandages, slings, finger braces, etc.)
  • Pharmacy charges
  • Suture, catheter, and other trays
  • IV fluids and supplies
  • Routine EKG monitoring
  • Oxygen administration and O2 saturation monitoring

Diagnostic procedures including lab and radiology may be billed separately and in addition to the emergency room services.

Hospital guidelines may be viewed in their entirety in Chapter 510 of BMS’ Provider Manual located here.

Billing Requirements for Outpatient Services Performed in Hospitals
Effective January 1, 2020, CPT/HCPCs codes are required to be submitted with the applicable revenue code for all outpatient services provided to Medicaid members in an acute or critical access hospital setting. Claims billed with revenue codes submitted without the corresponding procedure code(s) will be denied.

Attention: Non-Par Providers

Effective August 1, 2019, payment to out-of-network non-patient facing providers will only be reimbursed if an authorization is obtained prior to the service being conducted. 

Reimbursement for services prior authorized to out-of-network non-patient facing providers will be at 80% of the current WV Medicaid fee schedule. 

Failure to obtain prior authorization for any service performed by an out-of-network non-patient facing provider will result in claim denial.

Prescription Benefits

Pharmacy services for WV Medicaid managed care organization (MCO) members will be administered by the traditional fee-for-service pharmacy program. All prescriptions should be billed with the information below:

BIN 610164

Questions regarding claims processing should be directed to the Medicaid’s Fiscal Agent’s POS Pharmacy Help Desk at 1.888.483.0801. The vendor specification document can be found at www.wvmmis.com for further information regarding claims processing. 

Click here to access the most recent PDL chances for WV Medicaid members. 

Prepayment Review

Pregnancy and Prenatal

The Health Plan requires the completion of the prenatal risk screening instrument (PRSI) upon the initial encounter when the EDC date is determined for all MHT and WVHB members receiving maternity services. Physicians are asked to complete the prenatal risk screening form and fax it to The Health Plan at 740.695.5297.

The most recent version of the Prenatal Risk Form Instrument (PRSI) can be found on the WV DHHR’s Office of Maternal, Child and Family Health website at http://www.wvdhhr.org/mcfh/.

Dental Benefits

Dental providers should contact SKYGEN at 1.888.983.4690 or skygenusa.com regarding contracting, billing procedures, and benefits for Medicaid members.

SUD Waiver

The substance use disorder (SUD) waiver services for The Health Plan’s WV Medicaid members will be submitted directly to The Health Plan. This information may also be located on KEPRO’s website and MMIS website.