The maximum allowable fee amount(s) are calculated by utilizing the West Virginia Medicare fee schedule where:

West Virginia Medicare rate(s) plus 35%

The Maximum allowable fee amounts are regardless of where services are rendered. Medicare codes become valid for payment upon the national release dates and must be updated at that time for proper reimbursement. When allowed medical items or services are not recognized or priced by Medicare, the maximum allowable fee amount(s) are established using reasonable and customary amounts. 

WVOIC approved Managed Health Care Plans (MHCPs) are exempt from the WVOIC fee schedule methodology and may establish their own fee schedule(s).

Self-insured employers and private carriers may establish their own exclusive fees and/or coverage guidelines for medical items or services.

When workers’ compensation services are rendered out-of-state, the aforementioned methodology applies with the exceptions noted in W. Va. Code §23-4-3 (including §23-4-3(a)(4)). It is important that the best possible effort be made by all parties to agree on reimbursement prior to rendering service(s).

Please note that the absence or presence of a code does not indicate workers’ compensation coverage.