Out of Network Prior Authorization Update


Beginning June 4, 2012, APS Healthcare, Inc. and its’ subcontractor WVMI (the current Utilization Management Contractor (UMC) for the Bureau for Medical Services) will be covering all out-of-network requests that have previously been handled by BMS. 

A few reminders about out-of-network requests for services for WV Medicaid members:

  • ALL Out-of-Network services requested for WV Medicaid members require prior authorization by the Utilization Management Contractor (UMC) or the Bureau for Medical Services (BMS) before services are provided. 
  • Out-of-network services must be requested by an enrolled West Virginia Medicaid provider with required documentation of medical necessity AND justification of why requested service(s) cannot be obtained from an in-network provider.
  • Out-of-network services, with the exception of confirmed emergent situations, shall not be authorized or reimbursed when the requested service is available in West Virginia.
  • The treating out-of-network physician and facility must enroll as a West Virginia provider to be eligible for reimbursement, accept West Virginia Medicaid’s reimbursement as payment in full, and attach a copy of the approval form to the BMS’ Fiscal Agent billing form for payment consideration OR bill under the authorization number granted by the UMC if the request is entered into their systems.
  • As in all cases, prior authorization does not guarantee payment.

Any out-of-network request for a review area already in the APS Medical CareConnection® (e.g. acute inpatient services, will be requested using the APS C3 Medical UM CareConnection® application or corresponding fax request forms and selecting the out-of-network selection for the servicing provider. Any out-of-network requests handled by WVMI in their legacy system will continue to be handled in the same manner as they have always been (e.g. Imaging).

For requests that have historically been directed to BMS- BMS will forward the request to APS or direct the caller to fax the request for out-of-network service (attached form) and all supporting documentation to APS. To decrease the time necessary to address these requests they may now be sent directly to APS at 1-866-209-9632 or send by secure e-mail to wvmedicalservices@apshealthcare.com. Faxes and e-mails should be labeled Out-of-Network request. Providers with questions about out-of-network requests may contact APS at wvmedicalservices@apshealthcare.com or at 1-800-346-8272.

In cases where the Prior Authorization cannot be communicated to the out-of-network provider  by APS or WVMI through their system , the attached form approving the service will be completed, signed by the APS nurse, and sent back to the provider by APS (fax or secure e-mail) and call tracking will be initiated with Molina if necessary (out-of-network provider is not enrolled or is termed). It is the responsibility of the provider to enroll in WV Medicaid- the PA number cannot be sent and the claim cannot be paid, even when a service has been authorized, if the provider is not enrolled in WV Medicaid

In those instances where the prior authorization cannot be communicated directly to Molina upon provider enrolment, the out-of-network service provider will be directed to attach the completed form to their claim. If a denial of service is rendered by the UMC all appropriate notifications will be sent.

350 Capitol Street | Room 251 | Charleston, WV 25301 | Phone: (304) 558-1700 | Contact Us | Site Map
To view Nondiscrimination Policies and Plans, please click here.