Division of Plan Management and Integrity

  • The Office of Pharmacy Services establishes coverage and reimbursement policies for outpatient medications within federal guidelines.  Included within the program responsibilities are the federally-mandated prospective and retrospective drug utilization review activities; prior authorization of high-cost, high-risk, drugs and maintenance of a Preferred Drug list.  Drug coverage is provided to all Medicaid covered eligibility groups, including recipients enrolled in managed care organizations.  Directed by Vicki M. Cunningham.

 

  • The Office of Drug Rebate coordinates all activities involved in invoicing drug manufacturers for rebates for which the West Virginia Medicaid program is eligible, including tracking of drug rebate payments from drug manufacturers, reconciliation of amounts invoiced to actual payments received as well as meeting related reporting requirements.  Directed by Gail J. Goodnight

 

  • The Office of Managed Care is responsible for the administration and oversight of a risk-based managed care program, Mountain Health Trust which operates under an approved 1915(b) waiver. The Bureau contracts with four managed care organizations for the provision of medically necessary services for approximately 412,00 Medicaid members.  Directed by Susan L. Hall.


  • The Office of Program Integrity completes the activities required under 42 CFR Section 456. This mandate requires post payment review of paid claims to assure that the services were provided by eligible providers to eligible clients, that the services were medically necessary, appropriate to the patient’s medical condition, and were provided in conformance with the service definitions set forth in the Medicaid manuals. This unit uses tools such as on-site reviews, desk reviews, and analysis of paid claims data to meet this mandate. Directed byr Scott Winterfeld.

 

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