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 Diab Thomas at ddthomas@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. 

• I/DD Waiver CC Provider Registration Form
• I/DD Waiver CC Web User Request Form

Medical Services

Medical Services - Provider Enrollment Registration

• KEPRO Medical CareConnection® Self Registration/Enrollment Portal User Guide

Medical Services Forms and Memos:

• KEPRO Prior Authorization Modification Request Form
• Medical Services - WV CareConnection® Fax Cover
• Dental Services
  • Dental Services Prior Authorization Request Form
  • Orthodontic Criteria Form
• Durable Medical Equipment (DME)
  • CMN for DME
  • DME Prior Authorization Request Form
  • Cost Invoice
• Home Health
  • Home Health Services Prior Authorization Request Form
• Hospice
  • Hospice Services Prior Authorization Request Form
• Inpatient Services - Acute Hospital & Inpatient Rehabilitation <21
  • Inpatient Rehab <21 Prior Authorization Request Form
  • Inpatient Prior Authorization Request Form
• Lab/Radiology/Imaging
  • Lab/Radiology/Imaging Prior Authorization Request Form
  • Oncotype DX Prior Authorization Request Form
• Orthotic and Prosthetic Services
  • Orthotic/Prosthetic Services Prior Authorization Request Form
• Outpatient Surgery Services
  • Outpatient Surgery Prior Authorization Request Form
• Podiatry
  • Podiatry Prior Authorization Request Form
• Private Duty Nursing
  • Private Duty Nursing Prior Authorization Request Form
• Therapeutic Services - Physical & Occupational Therapy ~ Speech & Audiology ~ Cardiac & Pulmonary Rehabilitation ~ Chiropractic
  • Pulmonary Rehab Prior Authorization Request Form
  • Cardiac Rehab Prior Authorization Request Form
  • Chiropractic Prior Authorization Request Form
  • Speech Prior Authorization Request Form
  • Audiology Prior Authorization Request Form
  • PT/OT Prior Authorization Request Form
• Vision
  • Vision – Adult - Prior Authorization Request Form
  • Vision – Under 21 - Prior Authorization Request Form

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 Diab Thomas at ddthomas@kepro.com or call KEPRO at 304.343.9663.

• Socially Necessary Services Provider Registration Form
• Socially Necessary Services Web User Request Form

Socially Necessary Services Forms and Memos:

• Authorization Adjustment Request
• Bureau of Children & Families – Socially Necessary Services Invoice Instructions 
  • Invoice
• Bureau of Children and Families – Roll Back Memo Dec. 6, 2011
• Licensed Behavioral Health Centers – Documentation Requirements – Sept. 7, 2011