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Medical Policy and Clinical UM Guidelines

View our medical policies and clinical UM guidelines

Need to find a Doctor or Hospital? Check the Online Provider Directory.

Forms and Tools

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UniCare Provider Resources

The following forms and tools for West Virginia Medicaid Managed Care are available to our providers: Claim Forms:
Claim Form CMS-1500
Claim Form UB-04 CMS-1450
Claim Follow-Up Form
 
General Forms:
Provider Maintenance Form
Breast Pump Request Form
Assessment Transition Form
Recoupment Form
Pediatric Throat Infection Tracker Form
Tonsillectomy PCP Checklist Form
PCP Selection Form
Mental Health Consent Form
Case Management Referral Form
Diabetes Management Program Description
Fraud Referral Form
How to Bill for Immunizations Provided by the Vaccines for Children Program
Outreach Request Form
Prior Authorization Toolkit
Provider Grievance Form
Provider Acknowledgement of Receipt Form
Record of Referral to Specialty Care
Request for Preservice Review
UniCare Provider Request for Member Deletion from Primary Care Physician (PCP) Assignment
Weight Management Program Qualification Assessment Form
Interpreter Attendance Verification Form
 
Health Education Forms:
2015 Fax to Quit Referral Form
Asthma Management Program Description
Asthma Progress Chart Note
 
Pregnancy Assessment Forms:
Prenatal Risk Screening Instrument
Notice of Delivery Form
Newborn Enrollment Notification Report
Prenatal Program-Provider Steps to Take
Pregnancy Notification Report
Prenatal Program Gift Reward
Postpartum Checkup Form
Second Trimester - Re-assessment
Third Trimester - Re-assessment
Preventive Care Forms
 
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