Medical Billing Services in West Virginia
Billing, coding, credentialing and denial management for West Virginia practices, with Medicare claims through Palmetto GBA (Jurisdiction JM) and West Virginia Medicaid handled by people who know the rules.
Medical billing for West Virginia practices
West Virginia has a high share of Medicaid and Medicare patients, and many practices serve small towns in mountainous counties far from the nearest hospital. Highmark Blue Cross Blue Shield West Virginia leads the commercial market, and PEIA covers a large share of public employees. Most Medicaid members are enrolled in a Mountain Health Trust managed care plan, and Medicare Part B claims go to Palmetto GBA in Jurisdiction M.
SFA Solutions works with West Virginia practices remotely, from Charleston and Morgantown to Huntington, Beckley and the Eastern Panhandle. With thin margins and a heavy government payer mix, every denied Medicaid or Medicare claim matters. We submit most clean claims within 24 hours, track each MCO's rules, and follow up on open claims.
West Virginia at a glance
| Medicare contractor | Palmetto GBA, Jurisdiction JM |
|---|---|
| Medicaid timely filing | 12 months from the date of service for fee-for-service claims, with corrected or replacement claims allowed up to 24 months from the date of service when requirements are met; MCOs set limits in their provider contracts |
| NP practice authority | Reduced |
| Cities we serve | Charleston, Huntington, Morgantown, Parkersburg, Wheeling, Beckley, Martinsburg, Clarksburg, Fairmont, Bluefield |
What West Virginia billing involves
These are the programs and rules our team works with for West Virginia claims.
Medicare
Palmetto GBA · JMWest Virginia Part B claims are processed by Palmetto GBA in Jurisdiction JM. Medicare's filing limit is 12 months from the date of service, and appeals start with a redetermination within 120 days of the initial decision.
West Virginia Medicaid
West Virginia Medicaid and WV CHIP, administered by the Bureau for Medical Services (BMS), including the adult expansion group
Portal: West Virginia Medicaid provider portal operated by the BMS fiscal agent, for enrollment and fee-for-service claims
Medicaid managed care
Most members are enrolled in Mountain Health Trust managed care through Aetna Better Health of West Virginia, Highmark Health Options of West Virginia, The Health Plan of West Virginia or Wellpoint of West Virginia. Mountain Health Promise, administered by Aetna Better Health of West Virginia, serves children in foster care and certain other children.
Timely filing
12 months from the date of service for fee-for-service claims, with corrected or replacement claims allowed up to 24 months from the date of service when requirements are met; MCOs set limits in their provider contracts.
Commercial and Medicare Advantage
Highmark Blue Cross Blue Shield West Virginia is the largest commercial carrier, and the Public Employees Insurance Agency (PEIA) covers state and many local government employees. UnitedHealthcare, Aetna and Humana are major Medicare Advantage carriers.
Prompt pay law
W. Va. Code Section 33-45-2 requires insurers to pay or deny clean claims within 30 days of receipt if submitted electronically and within 40 days if submitted on paper, with 10% annual interest on claims paid late.
Nurse practitioners
Reduced practiceWest Virginia NPs need a collaborative agreement with a physician for prescriptive authority. After at least three years in a documented collaborative relationship with prescriptive authority, the Board of Nursing must authorize prescribing without one (W. Va. Code Section 30-7-15b). NPs bill under their own NPI.
Credentialing
Providers enroll with West Virginia Medicaid through the BMS fiscal agent and then credential with each Mountain Health Trust MCO separately. Highmark and most commercial plans rely on CAQH ProView, and PEIA has its own enrollment requirements. Medicaid enrollment must be revalidated at least every five years.
Billing challenges West Virginia practices face
A government-heavy payer mix
Many West Virginia practices see most of their patients through Medicaid, Medicare or dual coverage. Crossover claims, secondary billing and MCO rules for dual-eligible patients need careful handling to avoid unpaid balances.
Four MCOs plus fee-for-service
Members can be in any of four Mountain Health Trust plans, Mountain Health Promise or fee-for-service Medicaid. Eligibility must be checked at each visit, because the payer can change between appointments.
Border patients from five states
Practices near Ohio, Pennsylvania, Maryland, Virginia and Kentucky see patients with out-of-state Medicaid and commercial plans. Each requires its own enrollment and filing rules.
Our services in West Virginia
Medical Billing
Learn moreCredentialing & Payer Enrollment
Learn moreMedical Coding
Learn moreDenial Management
Learn moreA/R Recovery
Learn moreEligibility Verification & Prior Authorization
Learn moreMedical Billing Audit
Learn moreRevenue Cycle Management
Learn moreSpecialties we bill in West Virginia
West Virginia medical billing questions
What is the timely filing limit for West Virginia Medicaid?
BMS requires fee-for-service claims no later than 12 months from the date of service. Corrected or replacement claims can be submitted up to 24 months from the date of service if they meet the stated requirements. MCOs set their own limits in the provider contract.
Which MCOs serve West Virginia Medicaid?
Mountain Health Trust plans are Aetna Better Health of West Virginia, Highmark Health Options, The Health Plan and Wellpoint. Mountain Health Promise, run by Aetna, serves children in foster care.
How fast must insurers pay in West Virginia?
Under W. Va. Code Section 33-45-2, clean claims must be paid or denied within 30 days if filed electronically and 40 days if filed on paper. The law has exceptions, such as when another payer is liable.
Who processes Medicare claims in West Virginia?
Palmetto GBA is the Medicare A/B MAC for West Virginia under Jurisdiction M. Part B claims, appeals and enrollment changes go through Palmetto GBA.
Get a free billing audit for your West Virginia practice
We will review your recent claims and denials against West Virginia payer rules and show you what can be recovered.
Nearby states
Primary sources
- WV BMS Mountain Health Trust (Managed Care)
- WV Medicaid Provider Manual Chapter 100 General Information
- W. Va. Code Section 33-45-2
- W. Va. Code Section 30-7-15b
- CMS: A/B MAC Jurisdiction M (Palmetto GBA)
Payer rules change. Last reviewed against the primary sources above on . Confirm current rules with the payer before relying on them.
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