Provider InformationProviders 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. ReimbursementHealth 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 Accessing Claim and Eligibility Information Online Rational Drug Therapy Program Now Reviews Prior Authorization Drug Requests. Click here for more information. Common Specialty Medications
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. Wells 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 at www.wellsfargo.com/tpa. Also, Wells Fargo's fax back service allows the provider to bypass speaking to a customer service representative when calling to verify eligibility and copayments. Contact Wells 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 (formally HCFA) 1500 Claim Form to request reimbursement for services. Claims for all medical, dental and vision services should be forwarded to: Wells Fargo 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 Wells 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: WVCHIP Charleston, WV 25301 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 Wells Fargo at 1-800-356-2392 for precertification (of the service and where the service will take place) prior to a WVCHIP cardholder's admission to a hospital, skilled nursing facility, any other inpatient facility and the medical services listed below: Abortion, Allergy Testing, Arthroscopy (knee only), Cataract Surgery, Chiropractic Care and Treatment, Colonoscopy, Day Programs, Durable Medical Equipment (purchase or rental), Home Health Care, Hospice Care, Laparoscopy, Magnetic Resonance Angiography (MRA), Occupational Therapy, Pain Management Services, Partial Hospitalization, PET Scan, Septoplasty (with or without Adenoidectomy), Vision Therapy and Emergencies. *If the admission is an emergency, then a parent, guardian, family member, provider or other designated person must call Wells Fargo at 1-800-356-2392 within 48 hours of the admission, even if the child is discharged in less than 48 hours. Remember, for out-of-state care, the parent or guardian must contact Wells Fargo 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?
For more information about benefits, please review the Summary Benefit (p.d.f.) Plan and Provider Guide (p.d.f.). Click here to view WVCHIP's Notice of Privacy Practices. Q. Who do I call to preauthorize prescription drug coverage? A. Contact WVU's Rational Drug Therapy Program at 1-800-847-3859 Provider OutreachAs 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 a provider outreach order (p.d.f.) form to start your outreach efforts today. End of page, navigation to follow. |
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