West Virginia CompKey

CompKey brings effective tools to the claim management process, which reduces claim costs by channeling medical care through quality providers, providing appropriate care and focusing on timely return-to-work.

Additionally, mandatory grievance resolution procedures within the plan expedite grievance resolution and reduce frivolous litigation costs.

CompKey offers a comprehensive program that includes a personalized panel of physicians, return-to-work focused case management, proactive utilization review, a unique mandatory grievance process and quality assurance processes. Through proactive case management and full use of the state-mandated treatment guidelines dictated within West Virginia’s Rule 20, CompKey ensures appropriate care is provided to injured workers and ensures the most effective use of claims dollars. The various elements of the plan work together to ensure injured workers receive the appropriate care at the appropriate cost, facilitating successful resolution of claims. Additional information on our West Virginia CompKey Plus program is provided below.


PROVIDER LOOKUP

To access a full provider listing for the WellComp MHCP, please visit the 4COMP website at www.4compnetwork.com. Click on the “provider directory” at the top of the page and then select “4COMP WellComp MHCP” for the customer name. You may search for a specific physician or hospital, or view and/or download the entire provider directory.


PRE-AUTHORIZATION REQUIREMENTS
In accordance with West Virginia Code 85-20-9.10, the following procedures and services must be pre-authorized, except in the case of an emergency, before services are rendered.

  • Inpatient hospitalizations subsequent to the Date of Injury (emergency admissions are reviewed on a retrospective basis)
  • Transfers from one hospital to another hospital (emergencies do not require authorization)
  • Reconstructive and restorative surgeries
  • All surgeries
  • Purchase of TENS unit above the amount of $50.00
  • Treatment/supplies used in excess of three (3) months for TENS units
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    Click here to see the full list of pre-authorization requirements
    • Psychiatric treatment (does not include the initial psychiatric consultation)
    • Physical medicine treatment in excess of this Rule
    • Outpatient pain management procedures (epidural steroids, facet injections, etc.)
    • Medication not normally used in injury treatment and medication not listed on the preferred drug list, if applicable
    • Medication – Controlled Substance (in excess of this Rule)
    • Durable Medical Equipment in excess of $500.00
    • Brainstem evoked audiometry
    • Repeat diagnostic studies (Workers' Compensation no longer requires approval for the initial MRI, CAT scan, Myelogram, EMG and Nerve Conduction Studies)
    • Standard/analog hearing aids
    • Programmable/digital hearing aids
    • Replacement hearing aids
    • Repair of hearing aids over the price of $250.00
    • Hearing aid batteries over the allowed quantity of 50 per 6 months
    • Telephone amplification devices
    • Hearing aid assistance products (V5299)
    • Non-emergency ambulance transportation
    • Non-emergency air transportation
    • All vision services and items associated with vision
    • All physical and vocational rehabilitative services
    • Retraining expenses
    • All oxygen equipment, supplies, and related services
    • All nursing, nursing home, and personal care services
    • Home or vehicle modifications
    • Work hardening
    • Work conditioning; and
    • Dental procedures. In addition, the following durable medical equipment requires prior-authorization, although reimbursed at less than $500:
    • E0585 Nebulizer with compressor
    • E0607 Home blood glucose monitor
    • E0610 Pacemaker monitor
    • E0730 TENS, name brand
    • E0731 Garment for TENS/ neuromuscular
    • E0745 Neuromuscular stimulator, electronic shock unit; and
    • E0935 Passive motion exercise device.

When requesting preauthorization, please identify yourself as a West Virginia Managed Health Care Plan (WV MHCP) Provider, and fax the request and supporting documentation to the attention of “Pre-authorization” at 304-346-2687.


TREATMENT AND RTW
The WellComp MHCP adheres to the state-mandated West Virginia treatment guidelines dictated in Title 85, Rule Series 20 in the evaluation of medical services. For treatments and services not addressed by Rule Series 20, the WellComp MHCP utilizes the Official Disability Guidelines (ODG). Providers may obtain copies of these guidelines at the following websites:


SERVICE AREA MAP

Click to enlarge


GRIEVANCE/APPEAL
WellComp recognizes that given the complexity of issues in workers’ compensation cases, a medical grievance may arise surrounding the medical care, services, or supplies that are necessary to treat an injured worker. The objective of medical case management is to resolve medical issues through the initial clinical review process, coordination measures, effective communication, negotiation and education before the issue becomes a grievance.

The WellComp MHCP maintains a mandatory grievance process to address grievances filed with the WellComp MHCP on medical service determinations. Grievances for the rendition of medical services must be initiated in writing within 30 calendar days of receipt of the written medical decision. Grievances may be initiated by the employee, their representatives and/or health care providers. The WellComp MHCP will issue a written decision to the employee and provider within 30 days of receiving a written grievance.

An employee or health care provider relevant to the grievance that disagrees with the final grievance decision may protest the decision by contacting the Office of the Judges within 30 days of issuance of the final decision. You must send a written protest along with a copy of the final grievance decision to:

Office of Judges
PO Box 2233
Charleston, WV 25328-2233