Important Notices!
West Virginia Children's Health Insurance Program (WVCHIP) Claims Processing Update!
Beginning July 1, 2024, WVCHIP Pharmacy's Point-of-Sale claims will be processed by West Virginia Medicaid's claims processor, Gainwell Technologies. The WVCHIP pharmacy claims with dates of services beginning now through June 30, 2024, will continue to be processed by Express Scripts, the WVCHIP's current Pharmacy Benefit Manager. Please use West Virginia Medicaid's Bank Identification Number (BIN) 610164 and the Processor Control Number (PCN): DRWVPROD, for WVCHIP prescriptions drug claims with dates of services of July 1, 2024 and after. NOTE: The WVCHIP members will receive new member cards, prior to July 1, 2024, with updated information removing Express Scripts as the Pharmacy Benefit Manager. Member ID numbers are not changing.
For questions regarding the processing of the WVCHIP pharmacy claims as of July 1, 2024, please refer to HEALTH PAS Online - West Virginia Medicaid and WVCHIP's Provider and Member portals.
Further details specifically regarding the WVCHIP claims processing, including the BIN and PCN, is located in the current West Virginia Medicaid Vendor Specification Document D.0 on the Gainwell Technologies Pharmacy Forms webpage under the "Reference Material" tab.
West Virginia University (WVU) School of Pharmacy's Rational Drug Therapy Program (RDTP) will continue to manage prior authorizations and edit overrides for WVCHIP. You may contact the RDTP by calling 1-800-847-3859, and by fax at 1-800-531-7787. If you have any general questions regarding this update, please contact Gainwell Technologies' West Virginia 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 Enroll to Prescribe for Medicaid MembersOn and after October 17, 2018, West Virginia Medicaid will begin to deny all claims for prescriptions written by any prescriber not enrolled with West Virginia Medicaid. This includes advanced nurse practitioners, physician assistants and pharmacists who administer vaccines. Even though the facility you are employed by (clinic, hospital or pharmacy) is currently enrolled, individual prescribers must also be enrolled. Failing to enroll with West Virginia Medicaid as a prescribing provider could cause serious consequences for your patients.
The requirement for prescribers to enroll is a provision of the Patient Protection and Affordable Care Act of 2010. all prescribers serving Medicaid patients MUST enroll and their name and national provider identifier (NPI) must be recorded on claims for prescription medications submitted for Medicaid members on and after October 17, 2018. Providers may enroll as a billing provider or an ordering, referring, or prescribing (ORP) provider." ORP Only Provider" is a category for prescribers who write orders, refer, or prescribe medications, but do not actually submit claims to Medicaid for their services. "ORP Only Providers" may not bill Medicaid for services.
If you are not already enrolled, please visit the West Virginia Medicaid claims processor's, Molina Medicaid Solutions, website at: 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. A completed ORP application can be enrolled in five days. To prevent interruptions in Medicaid member's access to needed prescription medications, prescribers must make sure they are enrolled with West Virginia Medicaid.
For questions, please contact Gainwell Technology Provider Enrollment at 888-483-0793 or the Molina Pharmacy Help Desk at 888-483-0801.
The West Virginia Medicaid Pharmacy Program is an optional fee-for-service benefit offered to all eligible members, including those who are enrolled in Medicaid Managed Care plans. In Calendar Year 2014, West Virginia Medicaid reimbursed more than 6.5 million prescription claims for a total of over $377.6M. Most prescription and some over-the-counter medications are covered as defined by federal law and regulations. The Pharmacy Program uses a Preferred Drug List with criteria established for non-preferred products. Some medications may be limited in quantity, by gender, or prior authorization requirements.
Coverage policies and important information about the Pharmacy Program are found on this website and in the West Virginia Medicaid Provider Manual, Chapter 518, Pharmacy Services. Billing Instructions and other important information can be found on the Medicaid fiscal agent, Molina Medicaid Solutions' website https://www.wvmmis.com.
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