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Charleston, West Virginia

 

Please submit your completed form and any supporting documentation required to the address indicated on the form.

Enrollment Form

Add a new employee’s coverage selections to your plan. Electronic forms are also available through the client log in.

 

Change of Status Form
Change information regarding an employee’s coverage or personal information. Electronic forms are also available through the client log in.

 

Health Benefits Claim Form
Submit a medical claim.

 

Dental Benefits Claim Form
Submit a dental claim.

 

Vision Benefits Claim Form
Submit a vision claim.

 

Flexible Spending Account (FSA) Health/Dependent Care Enrollment Form
Add a new employee to this benefit.

 

Flexible Spending Account (FSA) Health/Dependent Care Enrollment Form Streamline (Automatic Rollover of Unreimbursed Expenses)

Submit this form for healthcare expenses that have not been, and will not be, reimbursed by any other medical or dental insurance.

 

Flexible Spending Account (FSA) Health Care Reimbursement Claim Form
Submit this form for reimbursement of health care expenses.

 

Flexible Spending Account (FSA) Dependent Care Reimbursement Claim Form

Submit this form for reimbursement of dependent care expenses.

 

Submit this form for reimbursement of dependent care, HRA, or health care expenses.

 

Health Reimbursement Arrangement (HRA) Claim Form
Submit this form to receive reimbursement from your HRA.

 

Initial Report Of Disability

Report an employee's short term disability claim.

 


WV PEIA/CHIP/Access WV Electronic Funds Transfer (EFT) Forms

 

WV PEIA/CHIP/Access WV Electronic Funds Transfer (EFT) Forms

 

EFT Termination Form

 


WV PEIA/CHIP Medical Home Forms

 

Cover Letter

 

Instruction Sheet

 

Physician Data Form

 

Payment Information Sheet

 


WV PEIA/CHIP/Access WV Prior Approval Requests

West Virginia Public Employees Insurance Agency Form
The WV PEIA Preferred Provider Benefit (PPB) plan requires for all services from:
Out-of-State, out-of-network providers
Network providers located in out-of-state counties beyond those counties bordering West Virginia
This form should be completed for PEIA members seeking prior approval

West Virginia's Children's Health Insurance Program Prior Approval Form
WV CHIP requires prior approval for ALL services provided outside the state of West Virginia (regardless of in-network or out-of-network status).
This form should be completed for WV CHIP participants seeking prior approval.

AccessWV Prior Approval Form
AccessWV requires prior approval for ALL services provided outside the state of West Virginia (regardless of in-network or out-of-network status).
This form should be completed for AccessWV participants seeking prior approval.

WV CHIP Pre-Certification Requests
 
West Virginia Children's Health Insurance Program Precertification Requests
WV CHIP requires precertification for inpatient stays and some outpatient procedures and therapies.
Pre-certification is usually the responsibility of the provider except for inpatient stays.
The form should be used when precertification is required.