West Virginia Workers Compensation Fee Schedule: Rates, Billing, and Disputes

The West Virginia workers’ compensation fee schedule caps what healthcare providers can charge for treating a workplace injury at the West Virginia Medicare rate plus 35%.¹ The Insurance Commissioner sets that ceiling under authority from state statute, and it governs most claims unless a managed care plan or self-insured arrangement displaces it.²

How the Rate Is Calculated

The schedule is built on the Medicare Resource-Based Relative Value Scale. Every procedure carries relative value units covering provider work, practice expense, and malpractice cost. West Virginia totals those units, multiplies by the Medicare conversion factor, then multiplies that result by 1.35. Whatever comes out of that calculation is the maximum a provider can bill for the procedure.³

Because the ceiling tracks Medicare, it moves whenever Medicare updates its conversion factor or relative value units. New Medicare codes become valid for workers’ compensation reimbursement on their national release dates, so providers who don’t refresh their code sets at the January 1 update risk billing problems. When a service has no Medicare price at all, the maximum falls back to reasonable and customary charges.¹

When the Schedule Doesn’t Apply

Two situations take a claim out from under the standard rate.

Employers who offer an Insurance Commissioner–approved Managed Health Care Plan are exempt from the schedule. These plans negotiate their own reimbursement rates directly with participating providers, and an employer operating under an approved MHCP can require its injured employees to use plan providers.² If your employer doesn’t use an MHCP, you generally choose your own treating physician, and that provider is paid under the Medicare-plus-35% default.

Self-insured employers and private carriers may also establish their own fee schedules or coverage guidelines for medical items and services.¹ Before relying on the posted methodology, confirm which arrangement applies to the claim in front of you.

Balance Billing: What the Worker Owes

In-state providers must accept the scheduled rate as payment in full. West Virginia law prohibits a provider from billing an injured worker for anything above the fee schedule amount, so if you were hurt on the job and treated in West Virginia, you should never receive a personal bill for covered treatment.²

Out-of-state providers are treated differently. If you choose a provider outside West Virginia who refuses to accept the scheduled amount as full payment, you are personally liable for the gap between that scheduled rate and the provider’s actual charge.² Two exceptions protect you from that exposure:

Emergencies. If you need immediate care to prevent death or serious permanent harm and end up at an out-of-state facility, you are not on the hook for the balance until your condition stabilizes and you can safely transfer to a West Virginia provider or an out-of-state provider who accepts the schedule.
No qualified nearby provider. When no reasonably nearby provider is qualified to deliver the care you need and willing to accept the scheduled rate, you can apply to the Insurance Commissioner for authorization to see someone else. Approval shields you from balance billing.

Billing Requirements for Providers

Getting paid at the right rate starts with the right form. West Virginia Code of State Rules § 85-20-9 sets the framework.⁴

Professional services go on the CMS-1500.
Institutional and facility services go on the CMS-1450 (UB-04).
Pharmacy charges use the online Point-of-Sale system, though a Universal Claim Form is also accepted.
Certain workers’ compensation–specific services require the Service Invoice form (WC-400).

Every bill must carry CPT codes for professional procedures and HCPCS Level II codes for supplies, equipment, and other medical services. HCPCS Level III codes are recognized for services unique to workers’ compensation. Written descriptions of procedures by themselves will not be accepted.⁴

Beyond the procedure codes, each bill needs the injured worker’s name, address, and claim number; the date of injury; the referring doctor’s name; the area of the body treated with appropriate diagnostic codes; dates, place, and type of service; charges for each service; and the provider’s name, address, and account number assigned by the insurer or Insurance Commissioner.⁴ Missing any of those fields is the fastest way to get a claim kicked back. Bills can be submitted electronically or by mail, but electronic submissions must follow the file format specifications of the applicable insurer.

When Payment Must Start

Once the employer or its insurer receives either the employee’s or the employer’s injury report, whichever arrives first, the Insurance Commissioner, private carrier, or self-insured employer has 15 working days to enter an order commencing payment of temporary total disability or medical benefits. The clock starts when that report lands along with a physician’s report or other information sufficient to make a determination.⁵

After a provider submits a complete bill, the insurer reviews it against the fee schedule and issues an explanation of the payment determination showing any adjustments. A bill can be denied if it’s incomplete or if the diagnosis doesn’t appear causally related to the workplace injury.⁴

Disputing a Reimbursement Decision

Disagreements over how the fee schedule was applied, denials based on causal relationship, and disputes over medical necessity all go through the Insurance Commissioner’s administrative process. An unfavorable initial decision can be escalated to the Office of Judges, and from there to the Board of Review, which must receive a request for review within 90 days of the final decision issued at the conclusion of all prior appeals.⁶ Providers who believe a bill was incorrectly reduced should hold onto the original submission, any resubmissions, and every payment explanation. Those documents are the record the reviewer will work from.

1
West Virginia Offices of the Insurance Commissioner. Medical Reimbursement
2
West Virginia Legislature. West Virginia Code 23-4-3
3
West Virginia Offices of the Insurance Commissioner. Detail Reference Guide to Determining CMS Medicare Plus 35 Percent for Workers Compensation Maximum Medical Reimbursement Fee Schedules
4
Legal Information Institute. West Virginia Code R. 85-20-9 – Coverage and Billing Provisions
5
West Virginia Legislature. West Virginia Code 23-4-1C
6
West Virginia Offices of the Insurance Commissioner. Board of Review