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Stream RCM handles medical billing, coding and insurance follow-ups for physicians, clinics, hospitals and other healthcare providers in West Virginia. Our certified medical billers and coders work with West Virginia Medicaid and its 4 Mountain Health Trust plans, Medicare through Palmetto GBA, Highmark Blue Cross Blue Shield West Virginia and the Public Employees Insurance Agency (PEIA). Every claim is coded from provider notes and tracked against its payer’s filing limit until it is paid.
Most West Virginia Medicaid denials come from the wrong plan on file, missing prior authorization or late filing. The Bureau for Medical Services (BMS) pays fee-for-service claims through Gainwell Technologies and contracts with 4 Mountain Health Trust managed care organizations (MCOs), each with its own claim edits and approval rules. Those 4 MCOs denied about 1.28 million claims in 2025, according to the BMS 2025 HB 4217 report.
MHT Members
Expansion Adults
MCO Auto-Enrollment
Billing rules in West Virginia change with each specialty and each patient’s plan. HealthCheck is West Virginia’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program for members under 21. Children in the West Virginia Children’s Health Insurance Program (WVCHIP) also join a Mountain Health Trust MCO. Children in foster, kinship or adoptive care belong to Mountain Health Promise, which Aetna Better Health of West Virginia runs alone. Pharmacy, long-term care and waiver services stay with BMS fee-for-service.
Our medical billing specialists work directly with West Virginia solo physicians, rural health clinics and hospital outpatient departments. Each account has one dedicated contact who follows BMS provider notices, Palmetto GBA updates and policy changes at Highmark and in PEIA.
Medical billing and coding in West Virginia follows 8 steps at Stream RCM: registration, eligibility, coding, charge capture, claim submission, payment posting, denial management and A/R follow-up.
Patient
Insurance EligibilityMedical
Charge
Claim
Payment
Denial
A/R and PatientWe record each patient's legal name, date of birth, address and Medicaid ID, including every other active policy. Mountain Health Trust members carry a Medicaid card and an MCO card, and BMS tells providers to check the MCO named on the card at every visit. West Virginia Medicaid is usually billed after Medicare, PEIA and commercial insurance plans.
Eligibility is checked before each visit through the West Virginia Medicaid portal or Voice Response System, but this does not guarantee payment. We also confirm which services need prior authorization with each plan. From January 1, 2027, some members aged 19 to 64 must meet community engagement rules under H.R. 1, starting with renewals due in March 2027.
Our medical coders assign Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD-10-CM) codes only when the note supports them. Codes follow the National Correct Coding Initiative (NCCI) from the Centers for Medicare and Medicaid Services (CMS). BMS does not pay for services documented with notes copied from earlier visits, so each note must stand on its own.
We compare visit notes, procedure logs and superbills (visit charge sheets) with the charges in your system before claims go out. Missed charges matter in West Virginia. BMS does not allow a service to be added to a Medicaid claim once that claim is more than 1 year past the date of service. Members also cannot be billed for missed appointments.
Fee-for-service Medicaid claims go to Gainwell Technologies, and Mountain Health Trust claims go to the member's MCO. Original Medicare Part A and Part B claims go to Palmetto GBA under Jurisdiction M (JM). UMR processes PEIA medical claims under its Preferred Provider Benefit plans. For dual eligible patients, Medicare pays first, and the Medicaid claim must reach BMS within 12 months of the Medicare payment date.
We post electronic remittance advice (ERA) and explanations of benefits (EOBs) as they arrive. BMS releases fee-for-service payments once a week, with each cycle starting on Friday, and requires electronic funds transfer (EFT). Medicaid members cannot be balance billed. We also check Qualified Medicare Beneficiary (QMB) status before statements, since QMB members owe no Medicare Part A or B cost sharing.
Each denial is traced to a coding, coverage or authorization error before resubmission. BMS accepts corrected or replacement claims up to 24 months from the date of service if the first claim was filed within 12 months and the remittance advice is attached. Rejection letters do not count as proof of timely filing. A fee-for-service prior authorization denial can be reconsidered if the request arrives within 60 days.
Our accounts receivable (A/R) follow-up team sorts unpaid claims by filing deadline, then by age and balance. Backdated coverage changes the deadline. For example, a patient seen on March 10 receives a backdated Medicaid card issued on August 1. That claim has 12 months from August 1, with a copy of the card attached. State-regulated commercial insurers may owe 10% yearly interest on clean claims paid late.
Outsourcing medical billing services can be a better option for West Virginia healthcare practices when staff, software and training costs exceed the fee based on monthly collections. It also helps when staff cannot keep up with 4 MCO rule sets, BMS notices and Palmetto GBA updates. The table below compares both options across 5 billing areas.
| Billing Area | In-House Billing | Outsourced to Stream RCM |
|---|---|---|
| Staff Costs | Salaries, benefits and training for billing staff | One fee tied to monthly collections |
| West Virginia Medicaid Filing Limit | Deadlines checked when staff have time | Each claim flagged before the 12-month limit |
| Mountain Health Trust MCO Rules | One workflow used for every Medicaid plan | Edits and approvals tracked for each of the 4 MCOs |
| Coding Reviews | Codes checked by the person who entered them | Codes checked against notes and NCCI edits |
| Reporting | Limited to what your software shows | Regular reports on claims, denials and A/R |
A medical billing company in West Virginia can also take on one task, such as credentialing or A/R follow-up, while your staff keeps the rest.
West Virginia practices can choose single billing services or hand their full revenue cycle to Stream RCM.
Claims are checked against payer edits, sent to Gainwell, Palmetto GBA, MCOs or commercial plans and tracked to payment.
Certified coders assign CPT, HCPCS and ICD-10-CM codes from each provider note and review modifiers before every claim leaves.
We review each denial, fix the issue within payer deadlines and record its cause to help prevent the same billing error from recurring.
Open claims are ranked by filing deadline, age and balance, then followed through payer calls, status checks and corrected claims until paid or closed.
Our provider credentialing team enrolls clinicians with BMS, all 4 MCOs, Palmetto GBA and Highmark, then tracks revalidation dates.
Stream RCM supports practices in every West Virginia county. Each card shows the county’s residents eligible for Medicare and the share enrolled in Medicare Advantage, from CMS data for March 2025 compiled by the Rural Policy Research Institute (RUPRI).
Charleston Area Medical Center serves Kanawha County, where 62.9% of 44,209 Medicare eligible residents use Medicare Advantage.
Berkeley County had 23,133 Medicare eligible residents and 48.0% in Medicare Advantage; Berkeley Medical Center serves Martinsburg.
Camden Clark Medical Center serves Wood County, where 52.7% of 21,525 Medicare eligible residents chose Medicare Advantage.
Cabell Huntington Hospital serves Cabell County, where 60.0% of 19,198 residents eligible for Medicare chose Medicare Advantage.
In Raleigh County, 47.0% of 18,329 Medicare eligible residents picked Medicare Advantage; Raleigh General Hospital serves Beckley.
Mercer County had 15,288 Medicare eligible residents and 59.2% in Medicare Advantage; Princeton Community Hospital serves Princeton.
Bridgeport's United Hospital Center serves Harrison County, where 57.3% of 15,258 Medicare eligible residents chose Medicare Advantage.
J.W. Ruby Memorial Hospital anchors Monongalia County, where 54.2% of 14,675 Medicare eligible residents chose Medicare Advantage.
Putnam County had 12,589 Medicare eligible residents, 62.4% in Medicare Advantage; CAMC Teays Valley Hospital serves Hurricane.
Only 45.3% of Jefferson County's 11,291 Medicare eligible residents chose Medicare Advantage; Jefferson Medical Center serves Ranson.
CAMC Plateau Medical Center serves Fayette County, where 55.8% of 10,679 Medicare eligible residents use Medicare Advantage.
Ohio County had 10,245 residents eligible for Medicare and 58.8% in Medicare Advantage, with Wheeling Hospital nearby.
Greenbrier Valley Medical Center serves Greenbrier County, where 51.8% of 9,346 Medicare eligible residents picked Medicare Advantage.
Logan Regional Medical Center serves Logan County, where Medicare Advantage covered 53.6% of 8,240 Medicare eligible residents.
Keyser's Potomac Valley Hospital serves Mineral County, where 40.4% of 6,991 Medicare eligible residents chose Medicare Advantage.
These figures are averages Stream RCM reports across client practices in many specialties. Results for your practice depend on payer mix, claim volume and current billing performance.
Fee-for-service claims must reach West Virginia Medicaid within 12 months of the date of service, and corrected claims are allowed up to 24 months. Medicare crossover claims have 12 months from the Medicare payment date. Each MCO sets its own limit in its provider contract.
Highmark Blue Cross Blue Shield West Virginia, which reports the largest share of the state’s commercial market, follows state insurance law. It must decide complete prior authorization requests within 5 business days, or 2 for urgent care. Medicaid MCOs follow BMS contracts, and Highmark Health Options needs its own enrollment. Self funded employer plans may differ.
Under House Bill 4335, the BMS fiscal agent must decide a complete Medicaid enrollment application within 5 business days. MCOs must finish credentialing within 60 calendar days of a clean application, with one 30 day extension allowed. Since July 1, 2026, all applications must be filed electronically.
PEIA claims go to the administrator for the member’s plan. UMR processes medical claims for the Preferred Provider Benefit plans, and Humana runs the Medicare Advantage plan for Medicare retirees. Since June 10, 2026, an approved PEIA member may switch to an equal or lower cost treatment without a new prior authorization.
Stream RCM pricing starts at 2.99% of monthly collections. Your rate depends on your specialty, claim volume and the services you choose, such as full billing, coding or credentialing alone.
Compare each company’s coding credentials, fees, reporting and reviews from practices like yours. Ask whether it already bills BMS, all 4 Mountain Health Trust MCOs, Palmetto GBA, Highmark and PEIA. A free review of your current claims shows how each company would handle your denials.
Send us your unpaid Mountain Health Trust claims, Highmark denials or slow PEIA payments. Our team will review them and explain where Stream RCM can help.
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