Forms and Enrollment
Behavioral Health
Behavioral Health Services - Provider Enrollment Registration
Providers must be enrolled with the Bureau for Medical Services (BMS) to provide clinic, rehabilitation, targeted case management, private practice psychiatric or private practice psychological services as well as Bureau for Behavioral Health and Health Facilities (BHHF) contract providers are required to submit data to KEPRO to receive prior authorization for services. Providers may submit either directly via the KEPRO website or through EDI submission. Providers must register with KEPRO. To register, contact Harry Cook at hcook@kepro.com or contact KEPRO at 304.343.9663.
- Behavioral Health Services Provider Registration Form - FQHC
- Behavioral Health Services Provider Registration Form - High Intensity
- Behavioral Health Services Provider Registration Form - LBHC
- Behavioral Health Services Provider Registration Form - LICSW
- Behavioral Health Services Provider Registration Form - Private Practitioners
- Behavioral Health Services Web User Request Form
Behavioral Health Forms and Memos
- Data Collection forms for CareConnection®
- CareConnection® Form for Core
- CareConnection® Form for Core +
- CareConnection® Form for Outpatient (tier 2)
- CareConnection® Form for Risk Assessment
- CareConnection® Form for Intensive Services
- CareConnection® Form for High Intensity
- CareConnection® Form for Offender Risk Assessment
- CareConnection® Form for Assessment
- CareConnection® Form for Discharge
- MCM – 1
- Behavioral Health Member Choice Form
- Authorization Adjustment Process
- Authorization Adjustment Request
I/DD Waiver - Provider Enrollment Registration
Before providers can submit or retrieve data, they must register with KEPRO. Registration includes submitting the Provider Registration Form for in addition to Web User Requests specifically for each user. For assistance, contact the KEPRO I/DD Waiver department at 866.385.8920.
Medical Services
Medical Services - Provider Enrollment Registration
Medical Services Forms and Memos
- KEPRO Prior Authorization Modification Request Form
- Medical Services - WV CareConnection® Fax Cover
- Dental Services
- Durable Medical Equipment (DME)
- Home Health
- Hospice
- Inpatient Services - Acute Hospital & Inpatient Rehabilitation <21
- Lab/Radiology/Imaging
- Orthotic and Prosthetic Services
- Outpatient Surgery Services
- Out of Network Services
- Podiatry
- Private Duty Nursing
- Therapeutic Services - Physical & Occupational Therapy ~ Speech & Audiology ~ Cardiac & Pulmonary Rehabilitation ~ Chiropractic
- Vision
Socially Necessary Services
Socially Necessary Services - Provider Enrollment Registration
Providers must be enrolled with the Bureau for Children and Families (BCF) to provide socially necessary services and those out-of-state providers with contracts with BCF are required to submit data to KEPRO to receive prior authorization for services. Before providers can submit data, either directly via the APS Web site or through EDI submission, providers must register with KEPRO. To register, contact Harry Cook at hcook@kepro.com or call KEPRO at 304.343.9663.
- Socially Necessary Services Provider Registration Form
- Socially Necessary Services Web User Request Form