Prior Authorization means that a health provider needs to get approval from a patient's health plan before moving ahead with a treatment, procedure or medication.
The idea is to ensure the health care is safe, necessary and appropriate for each patient. Medical necessity means that you really do need the service or drug your provider is prescribing.
When West Virginia Medicaid is trying to determine if the request meets medical necessity they are looking to see if the treatment is recommended for your situation according to up-to-date, research evidence.
The goal is for services or drugs being requested are both medically necessary and make financial sense.
Gold Card Program
West Virginia Medicaid Prior Authorization Exemption Gold Card Program allows certain providers to be exempt from getting a prior authorization if they a 90% prior authorization approval rate over a 6 month period on certain services. To keep the Gold Card status providers will be required to submit clinical documentation for services which have been rendered for evaluation. The services will be reviewed to make sure that the provider is performing at a 90% or higher level.
If they don't meet the requirements then their Gold Star Status will be removed and prior authorizations will be required before the service is rendered. After 6 months they may request a review.
If a group of providers share an office, only the performing provider that reached the Gold Card status will be eligible not the entire practice.
Any service that requires step therapy will continue to require completion of the step therapy. If the step therapy was unsuccessful then the provider may continue with the Prior Authorization process indicating the medication and/or therapies which have been attempted and failed.
Prior Authorizations should be submitted electronically when possible which makes the process more efficient.
Prior Authorization Service List
A listing of services which require prior approval is available to both providers and members.
For surgery Information click here
For Cardiac Rehabilitation click here
For Vision Information click here
Members who have coverage through one of the MCO's should select the link provided below for the information on Prior Authorizations.