Out of State/Out of Network Laboratory Services
PEIA would like to clarify a benefit change effective July 1, 2016. Out-of-state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart. This benefit change includes out-of-state, non-network laboratory services.
The PEIA Finance Board adopted benefit changes for Plan Year 2017, which began on July 1, 2016. A comprehensive list of these changes is available at www.wvpeia.com under News Center.
If you have questions about PEIA’s benefits or payment policies, please contact HealthSmart at 1-888-440-7342.
Maternity Services: Cesarean Sections
Effective 4/1/2017, any Cesarean section, labor induction, or delivery that follows labor induction and that occurs prior to 39 weeks of gestation will be denied if the procedure is not considered to be, and documented as, medically necessary or the result of spontaneous labor.
Physician claims for obstetric delivery will require one of the following modifiers:
UB-Medically necessary delivery prior to 39 weeks of gestation
UC-Delivery at 39 weeks of gestation or later
UA-Non-medically necessary delivery prior to 39 weeks of gestation
Records will be subject to retrospective review. If a Cesarean section, labor induction, or delivery following labor induction fails to meet the criteria for medical necessity, payments made will be subject to recoupment. Recoupment will apply to the physician charge for delivery.
If you have questions, you may call HealthSmart Benefit Solutions at 1-888-440-7342 or PEIA at 1-888-680-7342.
Molina Medicaid Provider 2017 Spring Provider Workshops Scheduled
April 3-13, 2017
4/3 Martinsburg-Holiday Inn
4/4 Wheeling-Oglebay Resort/Pine Room
4/5 Morgantown- Waterfront Resort
4/6 Vienna- Grand Pointe Conf. Center
4/10 Roanoke- Stonewall Resort
4/11 Charleston- Beni Kedem
4/12 Huntington- St. Mary's Conf Center
4/13 Beckley- Tamarack
Registrations begins at 8:00am Workshops are from 9:00-1:00pm and a light breakfast will be provided.
RSVP by March 17th by completing a registration form online
Subject Line: Attn: Spring 2017 Provider Workshop
You may also have received the flyer and you can fax or mail that registration to
304-348-3380 Fax: Attn: Spring 2017 Spring Workshop
Mail: Attn: Spring 2017 Provider Workshops
Molina Medicaid Solutions
PO Box 625
Charleston, WV 25322-0625
As of April 1, 2017, UniCare will no longer accept and review claims with medical records attached instead of prior authorizations.
If a claim for a service requiring a prior authorization (PA) is received with medical records attached in place of a required PA, the claim will be denied for lack of PA.
Certain services require a PA from the Utilization Management department. To determine which services require PA, use the PA tool on the Provider Resources page on the plan’s website,