The ProviderFocus Newsletter is your quarterly update on what’s new with The Health Plan. In each issue, you’ll learn about updates to practice guidelines, important deadlines, educational opportunities and more!

Browse our past and current newsletters:



New Vision Provider for Medicare Advantage Members

The Health Plan Medicare Advantage members (including SecureCare HMO, SecureChoice PPO and Dual-Eligible Special Needs Plan) will utilize Superior Vision for routine eye care beginning January 1, 2020.

Providers must be contracted with Superior Vision in order to treat Medicare Advantage members of The Health Plan.

Contact Superior Vision at Monday – Friday 8 AM – 9 PM EST to determine if you are a participating provider or to request to join their network.

Feel free to contact THP’s Medicare Customer Service number at 1.877.847.7907 if you have any questions.

Pilot Project Atlas

West Virginia is one of a small group of states selected to participate in a pilot project to develop and implement ATLAS™ - a quality measurement system for addiction treatment programs. This system will make information about the quality of care available to the public, treatment programs, referral sources, policymakers, and payers. For the pilot project, the West Virginia Department of Health and Human Resources’ Office of Drug Control Policy is partnering with Shatterproof, a non-profit organization dedicated to ending the devastation of addiction. A Treatment Facility Survey was shared with all addiction treatment programs in West Virginia on October 14, and must be completed before December 17. Completion of the Survey is a requirement for programs funded by DHHR’s Bureau for Behavioral Health. If you have not received the Survey or have any questions about ATLAS please contact

eviCore healthcare Will Conduct Prior Authorizations

The Health Plan (THP) has partnered with eviCore healthcare to manage medical necessity review and prior authorization for Commercial, THP Medicaid and Medicare populations for the following services effective December 16, 2019:

  • Radiology/Cardiology, including:
    • Advanced Imaging (including cardiac advanced imaging)
      • CT
      • MRI
      • PET
    •  Nuclear Medicine (non-cardiac)
  • Durable Medical Equipment and Sleep Studies

Effective January 1, 2020, eviCore will conduct medical necessity review and prior authorization for the Medicare population only for the following service:

  • Post-Acute Care, including:
    • Skilled nursing
    • Home health
    • Long term acute care
    • Inpatient rehab

To view available options to receive on-site or webinar orientations, please log in to the Provider Portal.

Changes to the Behavioral Health Pre-Authorization List

Effective July 1, 2019, the following have been added to the behavioral health pre-authorization list:

Inpatient Care Addition

  • Residential Adult Services for Substance Use Disorder Waiver: ASAM Level 3.1(H2036U1HF), ASAM Level 3.3(H2036U3HF), ASAM Level 3.5 (H2036U5HF) and ASAM Level 3.7 (H2036U7HF)

Ambulatory Services Addition

  • Peer Recovery Support (H0038)

Log in to to view the full behavioral health pre-authorization requirements list. 

PT/OT Services Now Managed by Palladian Health for Members with an Autism Diagnosis

Medical necessity review and prior authorization for physical therapy and/or occupational therapy services for members with an autism diagnosis will be managed by Palladian Health, effective July 1, 2019. Initial evaluations do not require pre-authorization and members may self-refer for evaluation. The following ICD-10 codes are grouped under pervasive developmental disorders and are included in this announcement:

  • F84.0 Autistic disorder
  • F84.2 Rett’s syndrome
  • F84.3 Other childhood disintegrative disorder
  • F84.5 Asperger’s syndrome
  • F84.8 Other pervasive developmental disorders
  • F84.9 Pervasive developmental disorder, unspecified

Medical necessity review and prior authorizations may be completed through The Health Plan online provider portal by logging in to, via fax at 1.844.681.1205, or telephonically at 1.877.244.8514. Questions on this new process may be addressed to The Health Plan at 1.877.847.7901 or by contacting your provider engagement representative.

WV Family Health Member Transition

West Virginia Family Health (WVFH) will no longer be participating in the Medicaid program with the Bureau for Medical Services (BMS) effective July 1, 2019. As such, current WVFH members will be transitioned to another managed care organization between May 1 and July 1.

WVFH members will be receiving a letter informing them that they must choose another managed care organization. These former WVFH members will have a 90-day transition period whereby The Health Plan (THP) will honor the prior authorizations for services already granted to WVFH. BMS will share those prior authorizations with THP and the list will be used during the transition phase for medical and claims processing.

The Health Plan’s prior authorization lists for medical and behavioral health services are located on the provider portal at New services and procedures requiring authorization by THP must be requested prior to performing the service or procedure. To avoid claim denials, please remember to verify eligibility at each visit.

Questions may be directed to the provider engagement representative for your county.

Click here to view the territory map or contact customer service at 1.811.613.8385.

Change in PEIA Out of State Facilities

Out of State In-Network and Tertiary Hospital List for PEIA Members

Effective July 1, 2019, the out of state facilities listed below may be utilized by West Virginia Public Employees Insurance Association (WV PEIA) members that selected The Health Plan as their health care insurer.

A tertiary facility is a facility that The Health Plan has contracted with to provide specialty medical and hospital services that are not normally available through in-network hospitals. Please note that prior authorization is required to access a tertiary hospital.

For more information access the Provider Portal

Introducing New Claim Editing Software

The Health Plan has implemented ClaimsXten, a new claims code editing software. This product was developed by Change Healthcare (previously McKesson) and it, or similar products, are widely used throughout the healthcare industry by Medicaid managed care organizations, health insurers, and third-party administrators across the nation to improve payment accuracy, reduce appeals and realize medical and administrative savings.

For more information access the Provider Portal

Substance Use Disorder (SUD) Waiver

Beginning July 1, 2019 the following services housed under the Substance Use Disorder (SUD) Medicaid Section 1115 Waiver will transition to managed care:

  • All residential services
  • Peer-to-peer recovery
  • Naloxone administration by ambulance transport

For more information access the Provider Portal