Prior Authorizations

Prior Authorization requires physicians and other health care professionals to obtain advance approval from Medicaid's Utilization Management vendor before a specific service is given to a member to qualify for payment coverage.

Gold Card Program

The Gold Card Program allows certain providers to be exempt from most prior authorization if they have a 90% prior authorizations approval rate over a six-month period.

If a group of providers share an office, only the performing provider that reached the Gold Card status will be eligible.

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.

Note: Gold Card Status does not remove fiscal authorizations for adult dental providers.

Prior Authorization Service List
Quick Reference for Prior Authorizations click here.
List of services which require prior approval is available to both providers and members:

For Surgical Services click here.
For Audiology Services click here.
For Cardiac Rehabilitation click here.
For Chiropractic Services click here.
For Dental Services under age 21 click here.
For Durable Medical Equipment click here.
For Hospice Services click here.
For Lab and Radiology click here.
For Occupational Therapy click here.
For Orthodic Services click here.
For Physical Therapy click here.
For Physician Administered Drugs click here.
For Podiatry Services click here.
For Private Duty Nursing Services click here.
For Pulmunary Service click here.
For Speech Therapy click here.
For Vision Service click here .

Managed Care Organizations Prior Authorization Links
Aetna Better Health of WV
The Health Plan
Highmark of West Virginia
Unicare