Announcements & Newsletters

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:



Implementation of Hospital Claims Editing Software

Effective October 1, 2020, The Health Plan (THP) will be implementing ClaimsXten, a claims editing tool developed by McKesson Information Solutions. ClaimsXten rules are clinically based and validated by a national panel of clinicians and medical experts.

THP previously implemented this software for professional claims and is now incorporating hospital claims.

The hospital claims edits will be applied across all THP product lines, which currently include Commercial, Medicare Advantage, Public Employees Insurance Agency (PEIA) and West Virginia Medicaid lines of business.

Some examples of ClaimsXTen edits include:

  • Deleted code edits
  • Gender edits
  • Age edits
  • Pre-operative visit, same day visit, post-operative visit bundling edits
  • Frequency validation: once or multiple times per date edits
  • Bilateral procedure edits
  • Multiple code re-bundling, multiple surgery, and assistant surgeon edits
  • Unbundling, incidental, mutually exclusive edits
  • Medicare and Medicaid-related Correct Coding Initiative (CCI) logic
  • Other Centers for Medicare and Medicaid Services (CMS) carrier directives          

As a result of THP’s ClaimsXten claims editing software, hospital providers will receive less post-payment audits and recoveries.

Please contact THP at 1.800.624.6961 with questions.

THP Following CMS & BMS Guidelines

The Health Plan is following the temporary measures related to healthcare services instituted by the Centers for Medicare and Medicaid Services (CMS) and the Bureau for Medical Services (BMS) during the coronavirus (COVID-19) pandemic.

Please refer to CMS guidelines related to COVID-19 for our members with Commerical (including POS, PPO, HMO, & WV PEIA) and Medicare coverage. Those guidelines may be accessed here. BMS guidelines related to COVID-19 will be followed by The Health Plan for our Medicaid members. Self-funded plans default to the group plan document.

The Health Plan is also following CMS and BMS guidelines for telehealth services rendered during the COVID-19 pandemic. Bill the appropriate CPT/HCPCs code and use "02" for the Place of Service if billing on a HCFA 1500 form. For Medicaid members only, if billing on a UB04 form, bill the appropriate CPT/HCPCs code with the -GT modifier.

These are temporary measures due to the COVID-19 crisis and The Health Plan reserves the right to re-evaluate at a later date. Contact The Health Plan at 1.800.624.6961 if you have any questions or need further assistance.

eviCore healthcare Will Conduct Prior Authorizations

The Health Plan has partnered with eviCore healthcare to manage medical necessity review and prior authorization for Commercial, THP Medicaid and Medicare populations for radiology/cardiology, durable medical equipment and sleep studies

eviCore conducts medical necessity review and prior authorization for the Medicare population only for post-acute care that includes skilled nursing, home health, long-term acute care and inpatient rehab.

Changes to the Behavioral Health Prior Authorization List

Effective July 1, 2019, the following were added to the Behavioral Health Prior 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)

View the full Behavioral Health Prior Authorization Requirements List under Prior Authorization and Referrals.

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. Initial evaluations do not require prior authorization and members may self-refer for evaluation.

Medical necessity review and prior authorizations may be completed through The Health Plan's secure provider portal, MyPlan, by fax at 1.844.681.1205, or by phone 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.

Introducing New Claim Editing Software

The Health Plan has implemented ClaimsXten, a new claims code editing software. Developed by Change Healthcare (previously McKesson) it is 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.