Enroll, certify, and sign provider agreement before billing

ADW agencies must enroll as Medicaid providers, sign the Provider Agreement, and be certified by the OA before providing or billing ADW services. Agencies must follow Chapter 300 Provider Participation Requirements and may not provide Medicaid services from an office location that has not been OA-certified and enrolled.

• Return signed Provider Agreement to the BMS fiscal agent before billing.
• Notify OA 45 calendar days prior to moving or opening a satellite office and complete Certification Application or ADW Change Request.
• Maintain ongoing compliance with chapter requirements after enrollment.

Follow UMC/OA/F/EA contractual roles for eligibility, certification, and claims

UMC, OA, and F/EA roles are contractually defined: the UMC makes initial and annual medical eligibility determinations and authorizes services; the OA certifies provider agencies and administers program operations and training; the F/EA administers Personal Options employer/fiscal functions and submits claims for self-directed members.

• UMC authorizes services based on assessed needs and provides service registration information to payers.
• OA certifies providers prior to enrollment and provides provider education.
• F/EA acts as fiscal/employer agent for Personal Options and submits claims on behalf of members/employers.

Complete OA certification, return Provider Agreement, and follow CAP/repayment requirements

Providers must complete OA certification and Medicaid enrollment before billing; OA notifies the BMS fiscal agent after satisfactory onsite review and the applicant must return the signed Provider Agreement. If reviews find disallowances, providers must submit a self-audit and CAP within 30 days and may face payment holds or repayment options (payment within 60 days, lien, or repayment schedule).

• OA schedules onsite review; waiver of onsite review only in limited previously-enrolled cases.
• If noncompliance found, submit self-audit to OPI and CAP to OA within 30 calendar days or risk pay hold.
• Repayment options include payment within 60 days, placement of lien, or up to 12-month repayment schedule.

Use EVV for personal attendant visits (except attendants living with member)

EVV check-in/check-out is required for services such as personal attendant care to verify service type, recipient, date/location, provider, and start/end times; personal attendants living in the member's home are not required to use EVV.

• Members or authorized representatives verify scheduled visits using the EVV system.
• Agencies are responsible for ensuring staff are trained on the agency's EVV solution.

Install FOB device when attendant cannot use EVV app and document installation

If a personal attendant cannot or will not use an EVV app, the personal attendant agency or case management agency staff may install a fixed object (FOB) device on a stationary fixture in the member’s home; the case manager must note FOB installation on the Monthly Contact form.

• FOB is an EVV alternative when attendee will not use app.
• Case manager documents FOB installation on Monthly Contact form.

Report suspected Medicaid fraud to OPI and ADW program manager

Providers must report suspected Medicaid fraud using the BMS fraud referral form and submit the completed form to OPI at DoHSBMSMedicaidOPI@wv.gov and to the ADW program manager.

• Notify all staff of reporting requirements and examples of fraud (falsified timesheets, duplicative claims, billing for services not provided).
• Complete and submit fraud referral form to OPI email and ADW program manager.

Respond to UMC contact attempts or risk referral closure after 10 business days

The UMC will attempt up to three contacts with applicants; if no contact is made within 10 business days the referral is closed and a new referral may be required if the MNER signature is over 60 days old.

• UMC issues a potential referral closure letter after up to three failed contact attempts.
• If referral closed, applicant may need a new referral if MNER signature >60 days.

Coordinate DHS-2 workflow and complete enrollment within 60 days

UMC routes DHS-2 forms to WV DoHS for financial determination and returns white DHS-2 to UMC after DoHS review; the applicant must be enrolled within 60 calendar days of the economic worker’s signature or the slot may be forfeited.

• UMC emails the yellow DHS-2 to DoHS to establish financial eligibility and emails white DHS-2 back after completion.
• Enrollment must complete within 60 calendar days from the date the economic service worker signed the white DHS-2 or slot may be forfeited.

Submit electronic service level change requests to UMC (no physician signature for increases)

Submit electronic service level change requests to the UMC when increasing service level during the service year; no physician signature is required for increases in this situation—only the ADW provider’s signature is required.

• Use the Aged and Disabled Waiver Request for Service Level Change form from the BMS website.
• Provide supporting documentation when submitting service level change requests.

Make required post-enrollment contacts and schedule assessments within set timeframes

After enrollment activation, case manager and personal attendant agency RN must contact the member within seven business days and schedule the Case Management Assessment within 14 calendar days; Personal Options vendor must make initial phone contact within three business days of enrollment.

• All agencies should attempt to meet together for assessments, share documentation within 14 business days, and upload documents to the UMC portal.
• If Personal Options member cannot hire staff within 90 calendar days, resource consultant notifies case manager to begin involuntary transfer process.

F/EA will submit claims and execute simplified Medicaid agreements for Personal Options members

Personal Options F/EA submits claims to the state's claim processing agent on behalf of the member/employer and executes simplified Medicaid provider agreements as part of administering the Personal Options model.

• F/EA manages payroll, processes invoices, pays vendors, and submits claims for self-directed members.
• F/EA provides orientation and ongoing employer supports to members acting as common-law employers.

Schedule and complete PCSP and assessments within 7–14 day timelines and upload to portal

Case manager must schedule Person-Centered Assessments and PCSP meetings promptly: contact to schedule within seven business days and complete assessments or hold the PCSP meeting within 14 calendar days; upload completed documents to the UMC portal within seven business days of completion.

• Person-Centered Assessments completed at least every six months and annually up to 45 days prior to anchor date.
• For Personal Options, the resource consultant forwards the PAL to the case manager and uploads PAL to the UMC portal within seven business days.

Bill case management using G9002 U1 monthly; document all contacts

Case management is billed using G9002 U1 at 1 unit per month (12 units/year); reimbursed monthly and does not require prior authorization. Case managers must document all contacts, complete monthly and quarterly contacts, and maintain required forms and records.

• Document date/time, description, and signature for each contact.
• Monthly calls and quarterly face-to-face visits required; initial contact and Monthly/Quarterly Contact forms must be used.

Obtain prior authorization and bill personal attendant services using S5130 (15‑minute units)

Personal attendant services require prior authorization and must be billed with S5130 procedure codes (modifiers denote model and living arrangements); service unit is 15 minutes and agencies must begin services within 10 calendar days after Service Plan development.

• Procedure codes: S5130 and model modifiers (e.g., S5130 U1, S5130 UK, S5130 U1 UK) as applicable.
• Upload original PALs to UMC portal; primary agency coordinates billable nursing units and ensures no duplication.
• Cannot bill for member being temporarily/semi-permanently out of state.

Maintain original PALs and upload PAL/PCSP documentation to UMC portal

Agencies must maintain original PALs in member files and upload PALs and required documentation to the UMC portal to verify services; all services must be legibly documented on the PCSP and in member records.

• Upload original PALs into UMC portal by the agency that created them.
• Maintain documentation for audits and monitoring; records retained per retention policies.
• Errors in documentation must be crossed out, initialed, and preserved.

Bill skilled nursing and non-medical transportation without prior authorization (observe limits)

No prior authorization is required for the listed skilled nursing (T1001-UD, T1002-UD) and non-medical transportation (A0160 U5/U4) codes; skilled nursing has specific limits (T1001 one annual event; T1002 six units/month) and transportation requires Service Plan/PAL documentation.

• Skilled nursing annual assessment T1001-UD: one event per calendar year; no prior auth.
• Skilled nursing services T1002-UD: six units per month, 15-minute units; no prior auth.
• Non-medical transportation A0160 U5 (Traditional) / A0160 U4 (Personal Options): one unit = one mile; 300 units/month; no prior auth.

Provide and bill PERS (S5161 U6) monthly without prior authorization

PERS is billed with procedure codes S5161 U6 (and S5161 U6 UK for Personal Options); units are monthly (1 unit = 1 per month), up to 12 units per calendar year; no prior authorization required.

• Case management agency or F/EA selects PERS vendor and documents choice in Service Plan.
• PERS vendor must provide 24/7 monitoring and meet documentation requirements.

Follow procedure codes and annual limits for EAA and Pest Eradication

EAA and Pest Eradication have specific procedure codes and per‑year limits: EAA-Home (S5165 U7) and EAA-Vehicle (T2039 U8) are $1 per unit with combined $1,000 per service plan year; Pest Eradication (S5121 U7 / S5121 U7 UK) is $1 per unit with $1,700 per service plan year; prior authorization is not required for EAA (Pest Eradication prior auth field not required in this section).

• EAA applications require assessments, physician statement, PCSP/Addendum, estimates/receipts and vendor payment to vendor (not member/staff).
• Pest eradication requests require WVDA-licensed vendor verification and Request for Pest Eradication form with supporting documentation.

Obtain prior authorization and use T2021 codes for adult medical daycare

Adult medical daycare uses procedure codes T2021 U4 (full day) and T2021 U8 (half day) with minimum hours defined and requires prior authorization; providers must be licensed and enrolled as ADW Medicaid providers.

• Full day minimum 7 hours; half day minimum 4 hours.
• Provider licensure via OHFLAC and compliance with rules required; prior authorization required before billing.

Request prior authorization for TMH pre-transition and community transition services

Pre-Transition Case Management (T1016 U1) and Community Transition Services (T2028 U1) require prior authorization; Pre-Transition is a one-time 24-unit (15-minute) service and Community Transition has a $4,000 (4000 unit) total expenditure limit per transition period (unit = $1.00).

• Submit prior authorization requests to UMC using established criteria.
• T1016 U1: 24 units one-time; T2028 U1: unit = $1.00; service limit 4000 units / $4,000 per transition period.

Submit Initial PC‑MNER to UMC and follow PC re-evaluation alerts

To request Personal Care (PC) services for ADW members submit an Initial PC‑MNER to the UMC; UMC uses the ADW PAS to determine PC eligibility and refer approved members to a PC agency. PC re-evaluations are signaled by an annual eligibility alert 90 days prior to anchor date.

• For initial PC requests, submit Initial PC‑MNER; if Waiver requirements met, UMC keys ADW PAS into PC web portal and refers member.
• Personal care agencies receive an annual eligibility alert 90 days before anchor date to begin re-evaluation.

Submit PC Plan of Care within 3 days and provide to agency within 7 business days

PC RN must submit the PC Plan of Care within three calendar days of the initial request and upload it to the UMC PC web portal; the ADW case manager must provide a copy of the PC Plan of Care to the ADW personal attendant agency within seven business days.

• ADW Person-Centered Assessments and PAL used when developing the PC Plan of Care.
• If dual services approved, ADW anchor date used for PC eligibility and documentation.

Ensure home health does not duplicate ADW services and document physician referral

Home health may be provided to ADW members only when services do not duplicate ADW services; home health must document physician referral and coordinate with the case manager and document need on the Service Plan or Service Plan Addendum.

• Home health limited to skilled nursing or therapy for post-hospitalization/acute episodes.
• Case manager ensures no duplication and maintains referral documentation in ADW records.

Continue services during transfer; upload required documents and meet receiving agency timelines

When transferring members, the transferring agency must continue services until the effective date, and upload PCSP, assessments, PAL, and other documents into the UMC portal at least three business days prior to the effective date; the receiving agency must schedule RN or Case Management Assessment within seven business days and complete assessments within 14 calendar days.

• Transfer effective date for case management is first of next month if received by the 17th.
• Transfer must complete within 45 calendar days from receipt of signed, correct, complete transfer request unless delayed by member or lack of provider.
• Receiving agency cannot bill for T1001 UD if an initial assessment was completed within the calendar year; may bill for T1002.

Upload discontinuation requests to UMC portal and follow OA/BMS discontinuation process

To discontinue services, case manager must upload Request for Discontinuation of Services with supporting documentation into the UMC portal; OA reviews and notifies member and agencies. For unsafe environments, OA and BMS may approve immediate discontinuation and notify authorities; effective date is 13 calendar days after OA notification if no hearing requested.

• Unsafe environment criteria and supporting documentation from multiple sources required.
• If a fair hearing is requested within 13 days, services may continue pending the hearing except in unsafe environment closures.
• Agencies submitting discontinuation requests must attend hearings if requested.

Submit prior authorization requests to UMC (UMC grants authorizations using BMS criteria)

The UMC is authorized to grant prior authorization for ADW services and uses BMS‑approved nationally recognized medical appropriateness criteria to review requests and authorize services.

• Submit prior authorization requests and supporting documentation via UMC processes/portal.
• UMC issues authorizations based on assessed needs and medical appropriateness criteria approved by BMS.