Prior Authorization & Referrals

WV Medicaid Prior Authorization Requirements Resumed

The Health Plan is reminding providers that the Bureau for Medical Services (BMS) temporary waiver of prior authorization due to the COVID-19 pandemic ended May 31, 2020 for WV Medicaid members. The need to authorize services that typically require prior authorization resumed June 1, 2020. Please direct any questions regarding prior authorization of services to the Medicaid Customer Service Department at 1.888.613.8385. 

Pharmacy Prior Authorization and Notification Requirements

To obtain prior authorization, call 1.800.624.6961, ext. 7914 or fax 1.888.329.8471 Attn: Pharmacy.

Newly approved, off-label and/or high-cost infusion drugs require prior authorization. Prior authorization forms are located here.

Traditional Pharmacy Drugs that require step therapy, exceed quantity limits, have criteria for coverage or are not on the formulary require prior authorization
Specialty Pharmacy

All specialty medications, oral and injectable, require prior authorization. These include, but are not limited to, medications for enzyme replacement therapy, growth hormone deficiency, hemophilia, hepatitis C, idiopathic pulmonary fibrosis, multiple sclerosis, oncology, psoriasis, pulmonary arterial hypertension, rheumatoid arthritis, and other relatively rare conditions. Dispensing of these medications may be limited to preferred providers

The Health Plan Pharmacy Services has a preferred specialty pharmacy network and will direct providers to the preferred specialty pharmacy. Access the list of specialty medications and prior authorization forms here, or call 1.800.624.6961, ext. 7914, option 4.

Note: Specialty pharmacy drugs are covered under the member’s drug rider. Members without an Rx rider do not have coverage for specialty medications. Members with Rx coverage with another carrier must seek coverage for specialty drugs with that carrier.
Office Administered Drugs

Dispensing of medications may be limited to preferred providers and all require prior authorization. The list below is not comprehensive:

  • Iron replacement therapy – parenteral (i.e., Ferrlecit, Infed, Venofer)
  • Injections to maintain high-risk pregnancy (i.e., Makena)
  • Viscosupplementation (i.e., Synvisc, Synvisc One)
  • RSV prophylaxis in high-risk infants (i.e., Synagis)
  • Osteoporosis treatment – parenteral (i.e., Prolia, Zolendronic Acid)
  • Ophthalmic injections for macular degeneration and macular edema (i.e., Avastin, Eylea)

Physical Therapy, Occupational Therapy and Chiropractic Providers

The Health Plan doesn't require prior authorization for the first 20 visits for chiropractic services and the first 20 combined visits for physical therapy (PT) and occupational therapy (OT) per event and/or year for our Commercial (HMO, PPO, POS, EPO & WV PEIA), Medicare and WV Medicaid members. Self-funded plans are excluded and default to the group plan document.

Our partner, Palladian Health, will review services for medical necessity and determine authorization status beginning with the 21st chiropractic and 21st combined PT/OT visits. If you have additional questions, please contact our Clinical Services Department at 1.800.624.6961, ext. 7644.

Retro Auth Guidelines

All participating providers are required to request prior authorization for services identified on THP’s prior authorization list before the service is rendered. This requirement includes both outpatient and inpatient services. Services rendered after hours, over the weekend or on a holiday, providers are required to request authorization the next business day. Prior authorization requests received after the next business day will not be processed. Failure to follow prior authorization guidelines will result in denied claims.

Services on The Health Plan’s authorization list rendered without prior authorization will be eligible for retro review only when deemed urgent/emergent. An urgent/emergent request is not applicable to prior authorization mandates and is defined as:

  • A request for medical care or service where application of the time frame for making routine or non-life threatening care determinations could seriously jeopardize the life, health, or ability to regain maximum function risk the safety of the member or others due to the member’s psychologic state or in the opinion of the provider, with knowledge of the member’s medical or behavioral condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

If Clinical Services determines that the service requested was not urgent/emergent, the request will be withdrawn by The Health Plan as a retro authorization request and will not be eligible for further review due to failure to obtain prior authorization. All other retro authorization requests will not be considered as the provider failed to meet their obligation to have the service authorized in advance of services being rendered. For all emergency issues, urgent/emergent transfers to tertiary facilities and for contacting the medical director after hours, please call THP’s Physician Access Line at 1.866.687.7347 24 hours a day/7 days a week.

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