West Virginia WV

WV Medicaid (BMS) expresses prior authorization two ways, both on the NEW standalone site bms.wv.gov (the old dhhr.wv.gov/bms/Pages/* deep links 404; only the BMS landing redirects). (1) PRIMARY PA-determination artifacts = ~17 per-service Prior Authorization Service Lists (PDFs) linked from /members/prior-authorizations, one per service category (Surgical, Audiology, Cardiac Rehab, Chiropractic, DME, Hospice, Lab/Radiology, OT, PT, Orthotic, Physician-Administered Drugs, Podiatry, Private Duty Nursing, Prosthetics, Pulmonary Rehab, Speech Therapy, Vision). These list the codes requiring PA. (2) Narrative PA criteria live inside BMS Provider Manual Chapters by service (Chapters 100-900) at /providers/policy-manuals; some chapters are direct /media/NNNNN/download PDFs, others are HTML pages. UM vendor = Acentra (formerly KEPRO), wvaso.acentra.com. PA submitted electronically. WV runs a Gold Card Program (90% approval over 6 months exempts a provider from most PA; step therapy still applies). Pharmacy is per-MCO PBM (FFS PDL via BMS pharmacy page). MMIS fiscal agent = Gainwell. Managed care = Mountain Health Trust. Also publishes 2026 CMS PA Metrics Reports (Medical + BH) per CMS-0057-F.

Last award: 2024-01-16 (HHOWV approval); 2024-07-01 (MHT SFY25 effective). Next due: Annual renewal each July 1; next reprocurement TBD (BMS RFA, not classical RFP cycle).

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How WV requires PA West Virginia (WV) Medicaid requires prior authorization (PA) for a variety of medical and non-medical services through its Managed Care Organizations (MCOs) and Fee-for-Service (FFS) programs. The requirements are detailed in specific service lists and provider manuals, which outline the criteria, documentation needed, and frequency limits for each service. For example, audiologic evaluations and treatments beyond standard service limits require PA every six months (codes 92506-92524). Similarly, custom diabetic inserts (codes A5513, A5514) are limited to six per year. Cardiac rehabilitation services (codes 93797, 93798) and pulmonary rehabilitation sessions (codes G0237, G0238, G0239) also require PA with specific service limits. Chiropractic manipulation treatments (codes 98940-98942) necessitate PA after 20 sessions in a calendar year. Radiologic examinations and computed tomographies for facial bones and skull beyond certain limits (codes 70100-70260, 70450-70492) also require PA, with additional restrictions based on age or modifiers. Vision care services such as orthoptics training (code 92065) for recipients aged ≤21 and contact lens replacement (code 92326) for those ≥21 require PA. Occupational therapy modalities and therapeutic procedures (codes 97012-97110) are limited to 20 visits per year for standard members, with higher limits for Alternative Benefit Plan members. Physical therapy services (codes 97012, 97014-97035) also require PA with a limit of 20 dates per year for standard members and 30 visits per year for Alternative Benefit Plan members. Specific documentation is required for each service to justify the medical necessity. ## 2. How WV publishes and reports PA WV Medicaid publishes its prior authorization requirements through multiple channels, primarily via the BMS (Bureau for Medical Services) website at `bms.wv.gov`. The site hosts per-service Prior Authorization Service Lists in PDF format, which detail the criteria for each service requiring PA. For instance, the `PA_ServiceList_Audiology.pdf` and `PA_ServiceList_Podiatry.pdf` documents specify the codes, frequency limits, and documentation requirements for audiologic evaluations and podiatric services. These lists are linked from the BMS website. Provider manuals also play a crucial role in detailing PA procedures. The `BMS_Manual_Ch506_DME.pdf`, for example, outlines the criteria for prior authorization for DME supplies such as syringes and insulin pump sets, with specific service limits per rolling month. The reporting of PA decisions is not explicitly detailed in the provided documents but likely follows standard Medicaid practices. Providers would submit PA requests through designated portals or systems, and decisions would be communicated back to them via these same channels. There is no mention in the source documents of a single centralized portal for all PA submissions and approvals, indicating that this process may vary by service type and MCO. ## 3. WV's CMS-0057-F and PA-reform compliance posture West Virginia Medicaid does not explicitly reference its compliance with CMS-0057-F in the provided documents. However, several aspects of its PA processes are consistent with the requirements outlined in that rule: 1. **Service-Specific Guidelines**: The detailed service lists (e.g., `PA_ServiceList_Audiology.pdf`, `PA_ServiceList_Podiatry.pdf`) provide specific criteria and documentation requirements for each service requiring PA. 2. **Provider Manuals**: The provider manuals (e.g., `BMS_Manual_Ch506_DME.pdf`, `BMS_Manual_Ch508_HomeHealth.pdf`) offer comprehensive guidance on the PA process for various services, including documentation and service limits. 3. **Gold Card Law (unverified citation)**: A WV Gold Card statute is referenced in the source synthesis, but the specific code citation was not grounded in the source documents and is flagged unverified pending confirmation. **WISeR is not applicable to WV** — the CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model applies only to AZ, NJ, OH, OK, TX, and WA. There is also no explicit mention of how WV Medicaid ensures public access to its PA policies beyond the per-service PDFs. ## 4. How WV runs its own program West Virginia Medicaid operates through a combination of Managed Care Organizations (MCOs) and Fee-for-Service (FFS) programs. The state's Medicaid program model is unspecified in the provided findings, but it includes several carve-outs and specific MCO assignments: 1. **Pharmacy Carve-In**: Pharmacy services are carved into the state (managed at the state level rather than per-MCO). 2. **Behavioral Health Carve-Out**: Behavioral health services for the general population are carved into the MCOs, while foster care behavioral health services are handled by a single MCO, Mountain Health Promise (MHP). 3. **Long-Term Services and Supports (LTSS) Carve-Out**: LTSS services are carved out to FFS, indicating that these services are managed directly by the state rather than through MCOs. 4. **Foster Care Program**: The foster care MCO program is specifically assigned to Mountain Health Promise (MHP), which handles behavioral health services for this population. The procurement cycle for MCOs is annual, with awards typically made in January and effective July 1st of the following fiscal year. For example, the last award was on January 16, 2024, with an effective date of July 1, 2024 (MHT SFY25). The next procurement cycle is scheduled for annual renewal each July 1st. The state has a history of transitions in fiscal agents, moving from ACS-Inc to Conduent/Gainwell. This transition affects the subdomains used by the state's systems, such as `*.acs-inc`, `*.conduent`, and `*.xerox`. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Service-Specific PA Requirements**: WV Medicaid has detailed service lists that specify the criteria for prior authorization, including frequency limits, documentation requirements, and age restrictions. - **Behavioral Health Carve-Outs**: Behavioral health services are carved out differently based on population (general vs. foster care), indicating a tailored approach to managing these services. - **Pharmacy Carve-In**: Pharmacy services are managed by the state rather than MCOs, suggesting a centralized approach to pharmaceutical management. ### What's Missing/Uncertain: - **Centralized PA Portal**: There is no mention of a single centralized portal for all PA submissions and approvals, indicating that this process may be fragmented across different systems or service types. - **Effective/Revised Dates**: Many service lists do not specify effective or revised dates, making it difficult to track changes over time. - **CPT/HCPCS Codes**: While some service lists provide CPT/HCPCS codes, others do not. This inconsistency can lead to confusion for providers and beneficiaries. - **Gold Card Statute**: The specific WV Gold Card statute citation is unverified in source documents. - **Program Model**: The exact program model (e.g., whether it's fully managed care or hybrid) remains unspecified. These gaps highlight areas where additional information would be beneficial to gain a more comprehensive understanding of WV Medicaid's prior authorization processes.