Prior Authorizations

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.
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 to make sure the 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 have a 90% prior authorization approval rate over a six-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 the provider does not meet the requirements, the Gold Star Status will be removed and prior authorizations will be required before the service is rendered. After six months, the provider 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.

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.
Fee For Service Link

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