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  1. www.peia.wv.gov › forms-downloadsForms & Downloads - peia.wv.gov

    Comprehensive List of Forms and Documents. Health Care Providers. Medicare Retirees. Non-Medicare Retirees. Life Insurance Forms, Documents, and Information . Notice of Privacy Practices. Requests for Proposals / Quotations / Information.

  2. peia.wv.gov › find-a-form-or-document › PagesFind a Form or Document - West Virginia

    ***If you have previously had PEIA as your insurance carrier, you are unable to use Manage My Benefits to log in and enroll. Please see your HR department to fill out paper enrollment forms. Forms. ABA Services Preauthor ization Form. Annual Routine Physical and Screening Examination Form. Authorization to Release/Disc lose Form

  3. peia.wv.gov › health_care_providers › PagesHealth Care Providers - West Virginia

    PEIA Prior Authorization Exemption Gold Card Program. In accordance with WV House Bill 2351, the Gold Card program was designed to allow six months of exemption from seeking prior authorization for providers who meet specific requirements.

  4. pharmacy.hsc.wvu.edu › media › 2239Pharmacy Prior Approval Program Form - West Virginia University

    Prior Approval Request Form. I. Patient and Medication Information. II. Prescriber Information. III. Pharmacy Information (if known) IV. Please answer each of the following questions for your request. 1. Has the patient been treated for the same diagnosis with other medication(s)?

  5. chip.wv.gov › SiteCollectionDocuments › ADD Med PA Request FormMicrosoft Word - PEIA and CHIP PA form 082009 - West Virginia

    Attention Deficit Disorder Medication Prior Approval Request Form. I. Patient and Medication Information. II. Prescriber Information. IV. Please answer each of the following questions for your request. 1. What is the diagnosis for which this drug is being prescribed? Attention Deficit Disorder (ADD) ADHD, Predominantly Inattentive Type. (314.00)

  6. www.umr.com › oss › cmsMedical Pre-Certification Requirements - UMR

    is required for the following services in WV: 1. Inpatient medical (non-surgical), 2. Inpatient surgical admissions (except those specifically listed as requiring precertification), 3. Inpatient mental health and substance abuse treatment 4. Maternity and newborn, and 5. Partial/day mental health or substance abuse treatment programs

  7. chip.wv.gov › SiteCollectionDocuments › PEIA PA form 082009Microsoft Word - PEIA PA form 082009 - West Virginia

    Attention Deficit Disorder Medication Prior Approval Request Form. I. Patient and Medication Information. II. Prescriber Information. IV. Please answer each of the following questions for your request. 1. What is the diagnosis for which this drug is being prescribed? Attention Deficit Disorder (ADD) ADHD, Predominantly Inattentive Type. (314.00)

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