Completing a West Virginia Medicaid prior authorization form starts with a question that has nothing to do with the form itself: is the patient enrolled in fee-for-service Medicaid or a managed care plan? That answer decides which form you download, which portal you use, and how long you wait for a decision. Get the enrollment path wrong and the request is rejected before anyone looks at the clinical question.
Check the Member’s Enrollment First
Fee-for-service members go through Acentra Health, the state’s administrative services vendor, with submissions routed through the WVMMIS provider portal. Managed care members go through their MCO’s own system, and the state has no authority to act on services the MCO manages.
West Virginia’s current MCOs are Aetna Better Health of West Virginia, The Health Plan of West Virginia, Highmark Health Options, and Wellpoint (formerly UniCare). The Bureau for Medical Services lists direct portal links for each plan’s prior authorization page.1Bureau for Medical Services. Prior Authorizations Verify enrollment on the member’s Medicaid card or through WVMMIS before you download anything.
Download the Right Form for the Service
There is no single universal form. Acentra Health publishes a separate fillable PDF for each service category, and using the wrong one delays processing. The forms cover:
- Inpatient admission
- Outpatient surgery
- Durable medical equipment (DME)
- Home health services
- Hospice services
- Inpatient rehabilitation
- Dental and orthodontic services
- Laboratory and genetic testing
All current forms are available on the Acentra Health WV ASO medical services page.2Acentra Health. Medical Services – WV ASO
Complete Every Field
The clinical sections vary by service, but the administrative fields work the same way across every form. Errors here are the reason most requests bounce back without a clinical review.
Member Information
Enter the patient’s full legal name and eleven-digit West Virginia Medicaid identification number exactly as it appears on the Medicaid card.3Bureau for Medical Services. Billing and Claims FAQs One mistyped digit means the system cannot match the request to an active member. Include the date of birth and any secondary insurance information.
Provider Information
The referring or ordering provider must be actively enrolled with West Virginia Medicaid. Enter the provider’s name, National Provider Identifier (NPI), and a phone and fax number where the state can reach the office with follow-up questions. Do not write “See Above” for provider fields when the same provider appears in multiple sections; the forms tell you to fill each one out.
Diagnosis and Service Codes
List the primary ICD-10 diagnosis with any relevant secondary diagnoses and symptom codes.4Acentra Health. West Virginia Medicaid Prior Authorization Form – Inpatient For procedures, enter CPT codes with descriptions in the service request fields.5Acentra Health. West Virginia Medicaid Outpatient Surgery Prior Authorization Form The diagnosis and procedure codes need to tell a coherent clinical story. If the diagnosis does not logically connect to the requested procedure, expect a denial or a request for more documentation.
Clinical Justification
This is where requests are won or lost. Include relevant test results, imaging, treatment history, and a clear explanation of why this intervention is needed now. Document any less intensive treatments the patient has tried and why they failed. “Patient needs surgery” accomplishes nothing. Attach supporting records directly to the form or include them as separate pages when faxing.
Pharmacy Requests Use a Different Process
Prescription drug prior authorizations do not use these forms. The Rational Drug Therapy Program (RDTP), operated through the WVU School of Pharmacy, handles all pharmacy PAs for West Virginia Medicaid and reviews medications on the state’s preferred drug list along with certain drug classes including home health products, injectable medications, and opioid prescriptions.6Rational Drug Therapy Program. Rational Drug Therapy Program
Pharmacy-specific forms are on the RDTP site. Providers can fax completed requests to 800-531-7787 or reach the RDTP help desk at 800-847-3859.7WVU School of Pharmacy. WVBMS Forms If a claim is denied and the prescribing physician cannot be reached, a pharmacy can dispense a 72-hour emergency supply at no financial risk while the authorization is resolved.8Rational Drug Therapy Program. PA Process FAQ
Submit Through WVMMIS or by Fax
For fee-for-service requests, the primary submission method is the West Virginia Medicaid Management Information System provider portal.9Medicaid Management Information System. Health PAS-Online Log in with your provider credentials, go to the prior authorization section, and upload the completed form along with all clinical documentation. The portal returns a confirmation with a tracking number. Online submission is faster and creates a digital trail if you need to resubmit records later.
If you cannot use the portal, fax the completed form and supporting documents. The fax number is printed at the top of each service-specific form, and DME, inpatient, and outpatient requests each route to different numbers. Sending to the wrong fax delays or loses the request. Keep the fax confirmation as proof of submission until the state enters the request into its system.
How Long the Review Takes
West Virginia Code ยง9-5-32 sets the deadlines for fee-for-service decisions. Once BMS receives a complete electronic submission, it has five business days to respond to a standard request. If the patient’s condition could seriously jeopardize their life, health, or safety, or if a treating provider believes delay would cause adverse health consequences, the state has two business days.10West Virginia Legislature. West Virginia Code 9-5-32 – Prior Authorization
Managed care members fall under federal rules at 42 CFR 438.210. Starting in 2026, MCOs must issue standard decisions within seven calendar days and expedited decisions within 72 hours where delay could seriously jeopardize the enrollee’s life, health, or ability to function.11eCFR. 42 CFR 438.210 Either timeframe can be extended up to 14 additional calendar days when the enrollee requests it or the MCO needs more information and can justify that the delay serves the enrollee’s interest.
The word that matters in every timeline is “complete.” If your submission is missing fields or documentation, the clock does not start until the reviewer has everything.
After the Decision
Providers can view status and the final determination letter in WVMMIS for fee-for-service requests, or in the relevant MCO portal for managed care. An approved authorization generates a specific number that must appear on all claims for that service. Bill without it and the claim will be denied for payment even though the service itself was approved. Members receive written notice by mail.
If the Request Is Denied
A denial is not the end. For fee-for-service denials, the treating provider can request a peer-to-peer review with a practitioner of similar specialty, education, and background. That consultation must happen within five business days of the request. The provider can also speak directly with the BMS medical director, who holds the final decision on the appeal, and the full appeal determination must be resolved within ten business days of submission.10West Virginia Legislature. West Virginia Code 9-5-32 – Prior Authorization
If the internal appeal does not reverse the denial, the member can request a state fair hearing through the Bureau for Medical Services. Written requests go to the WV Bureau for Medical Services / Office of Medicaid Managed Care at 350 Capitol Street, Room 251, Charleston, WV 25301-3708.12Aetna Better Health of West Virginia. File a Grievance or Appeal Questions about the fair hearing process go to the Department of Health and Human Resources at 304-558-0684. Members can designate a representative to act on their behalf.