Provider Resources

Beginning 07/01/2024, WVCHIP Pharmacy POS claims will be processed by West Virginia Medicaid's claims processor, Gainwell Technologies. WVCHIP Pharmacy claims with dates of service from now through 06/30/2024 will continue to be processed by ESI, WVCHIP's current Pharmacy Benefit Manager (PBM). Please use WV Medicaid's Bank Identification Number (BIN), 610164, and Processor Control Number, DRWVPROD for WVCHIP drug claims with dates of service of 07/01/2024 and after. NOTE: WVCHIP members will receive new member cards prior to 07/01/2024 with updated information removing ESI as the PBM. Member ID numbers are not changing.

For questions regarding processing of WVCHIP pharmacy claims as of 07/01/2024, please refer to Health PAS Online - WV Medicaid and WVCHIP's Provider and Member portals, located at this link: https//www.wvmmis.com

Further details, specifically regarding WVCHIP claims processing, including the above named BIN and PCN, is located in the current WV Medicaid Vendor Specification Document D.O. on the Pharmcy link on that page, under the "Reference Material" tab, here: https://wvmmis.com/Pharmacy/Forms/Allitems.aspx

WVU's Rational Drug Therapy Program (RDTP) will continue to manage Prior Authorizations (PA) and Edit Overrides (EO) for WVCHIP. RDTP's phone number is 1-800-847-3859, and the fax number is1-800-531-7787. If you have any general question regarding this update, please contact Gainwell Technologies' WV Medicaid and WVCHIP's Pharmacy Provider Help Desk at 1-888-483-0801. The help desk number for members is 1-888-483-0797.

Providers must be enrolled with WV Medicaid and CHIP to ensure that prescriptions are processed and paid. Failing to enroll as a prescribing provider could cause your patients' prescriptions to be denied at the pharmacy. If you are not already enrolled, please visit https://www.wvmmis.com and enroll online as a billing provider or as an "ORP Only Provider." The quickest enrollment option is the ORP-Only online application process. To prevent interruptions in member's access to needed prescription medications, prescribers must make sure they are enrolled with West Virginia Medicaid.

Provider Notice: WVCHIP Benefit Transition

Please see the following information regarding the ongoing transition to align WVCHIP benefits to WV Medicaid, due to the West Virginia Legislature's, House Bill 4649. Read here to see the complete notice.

Providers: Payment Error Rate Measurement (PERM) Review - Reminder to Submit Medical Records

The Centers for Medicare & Medicaid Services (CMS) Payment Error Rate Measurement (PERM) Program for Reporting Year (RY) 2023 is currently reviewing the WV Medicaid and WV Children's Health Insurance program (WVCHIP) to measure imporoper payments in order to maintain the integrity of the Medicaid program. The Review Contractor (RC) Empower AI is authorized to collect information from providers and to review documentation to ascertain adherence to Medicaid regulations. Please read here for additional information.

Up-to-Date Addresses

Please remind your patients to make sure their addresses are up-to-date. Some addresses have been changed by 911, Some have been changed because of moving, and other reasons. Click here for more Information.

Telehealth Policy

WVCHIP Telehealth Policy

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

Prescription Drug Plan

Current Preferred Drug List 
Express Scripts, Inc. (ESI) 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

Healthcheck Forms

Healthcheck Provider Manual and Forms
Kindergarten Screening Document

Dental Information

Dental Provider Guide
Dental Procedure Codes (2021)

Benefit Resources & Reimbursement

Reimbursement for Developmental Screenings

Applied Behavioral Analysis

Applied Behavioral Analysis Policy Update (Effective February 1, 2023) 

Pre-Authorization Requests

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.