West Virginia Medicaid offers a comprehensive scope of medically necessary
medical and dental health services. Any covered and authorized service must be
provided by enrolled providers practicing within the scope of their license,
utilizing professionally accept standards of care, and in accordance with all
State and Federal requirements. Enrolled providers are subject to review of
services provided to Medicaid members by the Bureau for medical Services (BMS)
whether or not the services require prior authorization. All practitioners must
maintain current, accurate, legible and complete documentation to justify
medical necessity of services provided to each Medicaid member and made
available to BMS or its designee upon request.
Any covered service
provided to Medicaid members must be medically necessary, cost effective, and
provided in the appropriate settings. The fact that a provider prescribes,
recommends, or approves medical care does not in itself make the care medically
necessary or a covered service; nor does it mean that the patient is eligible
for Medicaid benefits. It is the provider's responsibility to verify Medicaid
eligibility and obtain appropriate authorizations before services are
Medical services may require prior authorization and service
limitations. When services require prior authorizations, a request with
clinical documentation to justify medical necessity must be submitted to the
BMS's Utilization Management Contractor (UMC) for review and final
determination. To extend coverage beyond the initial prior authorization period
or when services limits are exceeded, prior authorization is
Coverage, prior authorization, service limitations, and special instructions of
medical services are available on the BMS website http://www.dhhr.wv.gov/bms2.
Medical services may be included in several of the Chapters of the BMS Provider
Manual. For example, Chapter 519 has information related to practitioner
services such as evaluation and management, preventive, emergency department,
outpatient hospital, telehealth, anesthesia, surgery, maternity, and specialty
services. Chapter 530 focuses on speech and audiology services; while Chapter
515 focuses on occupational/physical therapy.
Dental Retro PA
Retrospective review is available for Medicaid members in instances where it is in the dental practitioner’s opinion that a procedure that requires prior authorization is medically necessary and per recommended dental practices delaying the procedure may subject the member to unnecessary or duplicative service if delivery of the service is delayed until prior authorization is granted. In these instances, a request for prior authorization MUST be made by the provider within 10 business days of the date the service is performed. If the procedure does NOT meet medical necessity criteria upon review by the Utilization Management Contractor (UMC) then the prior authorization request will be DENIED and the provider cannot be reimbursed for the service.