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ModifiedWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

Chapter 502 — Children with Serious Emotional Disorder Waiver (CSEDW)

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Defines West Virginia Medicaid HCBS waiver program requirements, provider enrollment and qualifications, program description, medical necessity, and operational requirements for children/adolescents (ages 3–20) and their families participating in the CSEDW.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyChapter 502 — Children with Serious Emotional Disorder Waiver (CSEDW)

Policy CodePolicy N/A

Change TypeMaterial updates: timely filing (365 days) and BASC eligibility threshold revised to 60multiple administrative renames and clarifications

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionWraparound facilitators must complete the initial Plan of Care within seven days of waiver enrollment.

SourceLink

POLICY UPDATE CHANGES

Claims must be filed within 365 calendar days from the date of service; CSEDW providers must submit claims within 365 calendar days or BMS will not reimburse.

BASC functionality threshold for medical eligibility was changed from 70 to 60.

Changed language throughout to replace 'case management' with 'wraparound facilitation', and 'Person-Centered Plan' with 'Plan of Care'.

3–20age range eligible for waiver

365claim filing deadline (days)

60BASC eligibility threshold

7initial Plan of Care timeframe (days)

EVVEVV added

15max facilitator caseload

Coverage and Eligibility Criteria

CSEDW Coverage Principles

Coverage is limited to medically necessary CSEDW services provided under the waiver to eligible children/adolescents; services are in addition to State Plan coverage and must be documented and justified for medical necessity.

ALL of the following

Member is enrolled in CSEDW and meets program age criteria (3–20 years).
Service is medically necessary as demonstrated by documentation in the Plan of Care addressing diagnosis, level of functioning, clinical stability, available supports, and appropriate level of care.
Service is provided by an enrolled Medicaid provider practicing within scope of license and consistent with professional standards and BMS requirements.
Service is specified in a current, approved Plan of Care and is non-duplicative of Medicaid State Plan or other paid services.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyChapter 502 — Children with Serious Emotional Disorder Waiver (CSEDW)

Policy CodePolicy N/A

Change TypeMaterial updates: timely filing (365 days) and BASC eligibility threshold revised to 60multiple administrative renames and clarifications

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionWraparound facilitators must complete the initial Plan of Care within seven days of waiver enrollment.

SourceLink

On This Page

ALL of the following

Prior authorization obtained when required by policy (PA does not guarantee payment).
Documentation maintained in the clinical record to justify medical necessity and made available to BMS or designee upon request.
Services not described in this chapter are presumed non‑covered under the waiver unless otherwise authorized.

ALL of the following

Plan of Care is current (dated within past year) and reviewed monthly by the Child and Family Team (CFT).
If Plan of Care signature page or required documentation is missing or invalid, services under that Plan are not billable.

ALL of the following

No Medicaid‑reimbursed CSEDW services may be provided until the child/adolescent is activated with the MCO.
Claims must be submitted within 365 calendar days of service date or will not be reimbursed.

Coverage information not included in this excerpt: any additional coverage limitations or cross‑program coordination rules not present in this extract must be verified in the full chapter or with BMS.

Provider operational and reporting criteria

Operational requirements and reporting obligations for CSEDW providers.

ALL of the following

Staff must be age 18 or older, complete fingerprint‑based background checks, and not appear on the OIG Medicaid Exclusion List; see Chapter 700 (WV CARES) for details.
Required documentation (licenses, certifications, training records, collaborative agreements, psychiatric certifications) must be maintained in each employee's personnel file at the agency site.

ALL of the following

New staff must receive orientation within the first 10 days of employment and complete required CSEDW trainings (Figure 1) within 30 calendar days; certain trainings require competency testing (≥80%).
Training completion must be documented on WV-BMS-CSED-06 or an equivalent tracking system available for review by BMS or designee.

ALL of the following

EVV is required for specified services (e.g., Out‑of‑home respite and Independent living/skills building); staff providing EVV services must obtain individual NPIs and comply with EVV data capture and verification procedures.

ALL of the following

Incident reporting: critical incidents must be reported to the MCO immediately and within 24 hours; non‑critical reportable incidents within 5 calendar days. Suspected abuse/neglect/exploitation are critical and must also be reported to protective services and OHFLAC.
Mortality: wraparound facilitator must submit Mortality Notification (WV-BMS-CSED-11) to OHFLAC within 24 hours and to ASO and MCO within seven calendar days of awareness of a death.

ALL of the following

Providers must maintain confidentiality and obtain appropriate releases of information prior to sharing protected information except as permitted by law; access limited on a need‑to‑know basis.

ALL of the following

Providers must respond to ASO provider reviews and submit corrective action plans within 30 days when required; noncompliance may result in holds on payments.

CSEDW eligibility criteria

Eligibility and enrollment criteria for CSEDW:

ALL of the following

Applicant must meet CSEDW medical eligibility as defined in Section 502.14.1 (see medical eligibility criteria).
Applicant must be at least 3 years and no older than 20 years of age.

ALL of the following

Applicant must apply for or be enrolled in West Virginia Medicaid at time of eligibility or after Certificate of Approval; applicants unable to meet financial eligibility may utilize §435.217 Group when criteria met.

ALL of the following

Applicant must be a resident of West Virginia (proof of residency required) except DoHS custody cases; ASO must receive proof prior to assessment.

ALL of the following

Applicant must choose HCBS over institutional services and select the identified MCO and choose CSEDW over Assertive Community Treatment when applicable.

ALL of the following

Enrollment is based on chronological ASO receipt of a complete application and MECA approval; if no slot is available the applicant is placed on the Managed Enrollment List and must access services within 365 days of a slot offer or be discharged.

ALL of the following

Enrollee selects one approved wraparound facilitation provider using the Freedom of Choice form (WV-BMS-CSED-02); BMS reimburses only Medicaid‑enrolled providers.

CSEDW coverage and eligibility criteria

Medical eligibility requires ALL of the following three elements:

Eligible diagnosis: a diagnosable mental, behavioral, or emotional disorder meeting current DSM criteria (excluding V‑codes, substance use, and developmental disorders unless co‑occurring with an eligible disorder).

Functional impairment: substantial impairment defined by CAFAS/PECFAS Youth Total score ≥90 with supporting narrative documentation and BASC T‑scores >60 on two or more clinical scales; the child must be able to engage in CSEDW services.

PRTF Level of Care need: applicant must otherwise require PRTF level of care and be at imminent risk of PRTF placement (resided in PRTF within past six months, reasonable indication of placement within 30 days, or imminent risk of harm due to behaviors).

ALL of the following

Assessment and determination process: Independent Evaluation (IE) by IEN member submitted to MECA; ASO schedules IE, IE submits to MECA within 14 days, and MECA determines eligibility within 7 days of receipt; applicant notified by ASO.

Annual medical redetermination and appeals

Annual medical redetermination and appeal criteria for continuing CSEDW services.

ALL of the following

Continued medical eligibility requires meeting substantial impairment criteria and CFT input; ASO conducts reevaluation and may schedule reevaluation up to 90 days before the anchor date.

ALL of the following

Wraparound facilitator must submit updated CAFAS/PECFAS, Freedom of Choice form, and CANS Needs Domains to the ASO 45 calendar days prior to the anchor date.

TERMINATION CONDITIONS

If CANS indicates 'no evidence of need' AND CAFAS/PECFAS total score is <90, eligibility may be terminated.

ALL of the following

Appeals: Notice of Decision sent by certified mail; Request for Hearing must be submitted within 90 days to appeal; to continue services during appeal, Request for Hearing must be submitted within 14 days of receipt of Notice or reimbursement will cease.
After filing for a Medicaid Fair Hearing, a second medical evaluation may be requested and must be completed within 60 calendar days by a different IEN member.

ALL of the following

All present at reassessment must sign acknowledgment; disagreements may be appealed via Assessment Data Modification Request form.

Plan of Care billing, documentation, telehealth, transfers, and hold rules

Billing and documentation conditions for Plan of Care and CFT participation.

ALL of the following

Only the wraparound facilitator may bill for Plan of Care meetings, coordination, annual reassessment, six‑month progress review, redetermination meetings, and gathering updates from providers; other providers may not bill for participation.

ALL of the following

Plan of Care must include demographics, goals, assessment summaries, medications, identified services and supports, therapy plan, behavior support plan, crisis plan, and original dated signatures with participation times and credentials.

ALL of the following

Telehealth: many CFT activities may be provided via telehealth up to 50% of total services; telehealth attendees must sign within 10 business days and Plan copies forwarded to CFT members and MCO within 14 calendar days; missing valid signatures invalidates billing.

ALL of the following

If child is hospitalized or placed in residential facility, services may be placed on hold and can resume if accessed within 365 calendar days; transfers require Transfer form (WV-BMS-CSED-15) to MCO within seven calendar days and full file transfer within 14 calendar days.

Wraparound Facilitation Coverage Criteria

Wraparound facilitation is a covered CSEDW service with specified provider qualifications, documentation requirements, service limits, and delivery modalities.

ALL of the following

Service limits: up to 12 units per Plan of Care year; caseload capped at 15 members per facilitator (members on hold excluded).

ALL of the following

Telehealth: available with POS 02; telehealth may be used for up to 50% of total services per calendar year; telehealth justification and backup plan must be in the service note and Plan of Care.

ALL of the following

Provider qualifications: licensed social worker, professional counselor, or RN OR BA/BS in human services with ≥1 year post‑grad experience OR Associate degree with ≥2 years experience plus BMS online case management certification; CANS certification and state wraparound training required.

ALL of the following

Documentation: maintain individual permanent clinical record with required demographics and provider/guardian info; a specific note for each billed activity and signed case notes for each home visit; progress notes must include date, signature, relevance to Plan goals, purpose, outcome, contact type, and location.

ACUITY CONTACT REQUIREMENTS

Moderate acuity (CAFAS/PECFAS 90–130): biweekly contact with minimum monthly face‑to‑face contacts.
High acuity (CAFAS/PECFAS 140+): weekly contact with minimum two monthly face‑to‑face contacts.

ALL of the following

Conflict of interest: wraparound facilitator and employing agency generally cannot provide other waiver or State Plan services for the same child unless exception authorized by BMS; agency must allow freedom of choice for providers.

Monitoring and reassessment requirements

Monitoring, reassessment, and transition criteria.

ALL of the following

Six‑month reassessment: CAFAS/PECFAS every 6 months for children who have met <50% of goals to determine acuity and Level of Care.

ACUITY TO LOC

CAFAS/PECFAS ≥140 → higher Level of Care.
CAFAS/PECFAS 90–130 → moderate Level of Care.
If CAFAS/PECFAS <90 at six‑month review → remain at moderate Level of Care during transition/discharge.

ALL of the following

ASO must schedule an Independent Evaluation within 72 hours, make contact within 30 calendar days (three attempts), and send completed assessment materials to the MCO within 48 hours of completion.

ALL of the following

Transition planning: children reassessed at moderate or below should begin transition planning; ASO has 14 days to submit Fair Hearing forms when applicable.

Service coverage criteria

Service eligibility, limits, and documentation requirements.

ALL of the following

Prior authorization: approved authorization dated prior to service initiation must be included in the record and Plan of Care for Independent living/skills building, Job development, Supported employment, and Specialized therapy; community transition and assistive equipment require MCO approval before purchase.

ALL of the following

Service units and limits: many services billed in 15‑minute units; combined weekly cap up to 160 units for Independent living, Job development, and Supported employment; age restrictions apply (Independent living/job development: 15–20; Supported employment: 18–20).

ALL of the following

Documentation: service note required for each instance/day including provider name, date, start/stop time, service code, signature and credential; Specialized therapy must document progress toward goals and is limited to $1,000 per Plan year combined with assistive equipment.

ALL of the following

Telehealth limits: Independent living/skills building telehealth allowed up to 25% of services per enrollment year with justification and backup plan in Plan of Care; other services have telehealth allowances per service definitions.

Coverage criteria for extracted services

Services are covered when medically necessary, documented in a current Plan of Care, prior authorized as required, non‑duplicative, and delivered by appropriately credentialed staff.

ALL of the following

Service inclusion: service must be specified in the Plan of Care and linked to goals/objectives; Plan must be current and valid to support reimbursement.

ALL of the following

Authorization and funding: MCO prior authorization required for reimbursements and purchases (assistive equipment, community transition, respite); funding requests for community transition are submitted by the wraparound facilitator and, if approved, the wraparound agency invoices the MCO.

ALL of the following

Limits and exclusions: assistive equipment up to $1,000 per Plan year (combined with Specialized therapy); community transition up to $3,000 one‑time for ages 18–20; family therapy and in‑home family support up to 8 units/day; peer parent support up to 8 units/week; respite combined limit up to 24 calendar days/year; many items are excluded from community transition purchases.

ALL of the following

Telehealth: allowed for certain services (family therapy, in‑home family support, peer parent support) up to 50% of annual services with justification in service note; respite and assistive equipment not available via telehealth.

ALL of the following

Staffing and procurement: staff credential requirements apply per service; assistive equipment must be purchased from an established business/qualified entity and documented by dated itemized receipt; community transition purchases are procured by the wraparound agency after MCO approval and the young adult is not reimbursed directly.

Coverage criteria for CSEDW services

Services are available under CSEDW when documented in a current Plan of Care and meet program rules and limits.

ALL of the following

Plan of Care validity: service must be included in an approved Plan of Care dated within the past year and reviewed monthly by the CFT.
Non‑duplication: services must not duplicate Medicaid State Plan services and must be additional to State Plan/EPSDT services.

ALL of the following

Respite and transportation limits: respite combined (in‑home + out‑of‑home) up to 24 calendar days/year; transportation limited by mileage (800 miles/month) and foster families are excluded from certain reimbursements.

ALL of the following

Provider requirements: providers must be licensed in WV, enrolled in Medicaid, and contracted with the MCO; services must conform to Plan of Care goals.

Eligibility and operational coverage criteria

Medical eligibility and operational coverage criteria — instruments, thresholds, and process requirements.

ALL of the following

PRTF Level of Care: applicant must require a PRTF Level of Care (resided in a PRTF within past six months or be at imminent risk of PRTF placement) as defined in policy.

ALL of the following

Functionality measure: BASC threshold for medical eligibility set to T‑score 60 (updated from 70).

ALL of the following

Independent Evaluation: IE must include background, behavioral observations, documentation across six major life areas, developmental history, mental status exam, diagnosis, and prognosis and be completed by an IEN member.

ALL of the following

Operational rules: no Medicaid‑reimbursed CSEDW services may be provided until child/adolescent is activated with the MCO; claims must be filed within 365 days of date of service.

ALL of the following

Initial case plan: initial case plan must be completed within seven days of waiver enrollment per updated Plan of Care requirements.

POC, meetings, documentation, EVV, and provider rules

Plan of Care and CFT meeting requirements, EVV, and provider rules affecting continuing eligibility and documentation.

ALL of the following

Initial Plan of Care: must be completed within seven days of waiver enrollment and include interim services, crisis plan, and date for master Plan if not completed at seven‑day meeting.

ALL of the following

CFT meeting cadence: 30‑day/90‑day meeting cadence and documentation clarified; '90‑Day Review' added; Plan reviews and significant life event, transfer/discharge meetings guidance added.

ALL of the following

Continuing eligibility: based on documented progress with the Plan of Care; suspension of waiver services may occur per clarified language.

ALL of the following

Service documentation and authorization updates: added requirements for Independent Living/Skills Building, Job Development, Supported Employment, Specialized Therapy, assistive equipment, community transition, and respite; EVV requirements added for specified services.

ALL of the following

Provider rules: foster parents cannot be reimbursed for non‑emergency medical transportation; Peer Parent Support no longer requires certification; mobile crisis moved to SPA effective 1/1/24.

Procedure Codes, Units, and Service Limits

Service-level documentation requirementsmixed

Each service code in this manual describes required documentation; providers must document service code, service provided, date, start/stop times, provider signature and credentials.

Assessment componentsmixed

Independent evaluation required to include most recent BASC

Not specifiedmixed

No explicit CPT/HCPCS/ICD codes provided in this excerpt

Wraparound Facilitation Procedure CodesCPTCovered

T1016HA-TF	Wraparound facilitation, moderate intensity
T1016HA-TG	Wraparound facilitation, high intensity

CSEDW service codes in this sectionmixedCovered

H2033-HA	Independent living/skills building (15-minute unit)
T2021-HA	Job development (15-minute unit)
T2019-HA	Supported employment, individual (15-minute unit)
G0176-HA	Extended professional services: specialized therapy (dollar-based unit)

Service Procedure Codes in this extractmixed

T2035-HA	Assistive Equipment
T2038-HA	Community Transition
H0004-HO-HA	Family Therapy
H0004-HA	In-Home Family Support
H0038-HA	Peer Parent Support
T1005-HA	Respite Care, In-Home

CSEDW service codes referencedHCPCS | mixedCovered

T1005-HA	Respite Care, In-Home
T1005-HA-HE	Respite Care, Out-Of-Home
A0160-HA	Transportation (per mile)
T1016-HA	Wraparound Facilitation
H0004-HOHA	Family Therapy (telehealth allowed up to 50%)
H0004-HA	In-Home Family Support (telehealth allowed up to 50%)
H0038-HA	Peer Parent Support (telehealth allowed up to 50%)

Claims data requirementsmixed

No codes listed

Telephone consultation / reports billingmixed

No codes listed

No codes in this extractmixed

No codes listed

No clinical/coding changes presentmixed

No billing/coding changes presentmixed

Wraparound facilitator caseload

Maximum caseload15 children/adolescents per wraparound facilitator

Waitlist conditionFacilitator must have at least 10 active cases before placing any member on a waitlist

Notification requirementIf requesting exception to exceed cap due to vacancy, facilitator must notify the MCO in writing within 48 hours

Functional impairment threshold

CAFAS/PECFAS thresholdYouth Total score of 90 or above

BASC requirementT-scores greater than 60 on two or more clinical scales

Supporting documentationFunctional impairment must be supported by narrative descriptions and other relevant records (IEP, prior testing, treatment records)

CAFAS/PECFAS termination threshold

Termination criteriaEligibility may be terminated if CAFAS/PECFAS total score is less than 90 overall and CANS indicates 'no evidence of need'

Reassessment roleCANS Needs Domains and CAFAS/PECFAS are reviewed by MECA during redetermination

Appeal optionTermination decisions can be appealed via Medicaid Fair Hearing per policy

CFT meeting frequency

Minimum frequencyChild and Family Team (CFT) must meet at least monthly to review and update the Plan of Care

Initial master plan reviewMaster Plan of Care must be developed within 30 calendar days of enrollment (or at the 7-day meeting) and reviewed regularly thereafter

DocumentationWraparound facilitator must document invitations, minutes, case notes, and submit updated Plan of Care to MCO within 14 calendar days

Telehealth utilization limit

Annual telehealth capTelehealth may be used for up to 50% of total services per calendar year for approved services (wraparound facilitation, family therapy, in-home family support, peer parent support)

Independent living limitIndependent living/skills building telehealth limited to 25% of annual services with telehealth backup plan

Telehealth justificationTelehealth use requires justification in the service note and a telehealth backup plan in the Plan of Care

Face-to-face meeting frequency by acuity

Moderate acuity (CAFAS/PECFAS 90-130)Minimum one monthly face-to-face meeting; biweekly contacts overall

High acuity (CAFAS/PECFAS 140+)Minimum two monthly face-to-face meetings; weekly contacts overall

Purpose of face-to-faceIn-person meetings verify health/safety, assess progress, update crisis plan, and monitor service delivery

Combined weekly service unit cap

Combined weekly capUp to 160 units per calendar week (combined across independent living/skills building, job development, supported employment as appropriate by age)

Unit incrementService unit for H2033, T2021, T2019 is 15 minutes

Age restrictionsIndependent living/job development: recipients 15–20; supported employment: recipients 18–20

Specialized therapy annual limit

Annual dollar limitSpecialized therapy (G0176-HA) limited to up to $1,000 per Plan of Care year combined with assistive equipment

Prior authorizationAssistive equipment and specialized therapy expenditures must be prior authorized and included in the Plan of Care

DocumentationSpecialized therapy plan must document sequential steps, measurable objectives, and progress toward goals

Service limits and modality thresholds

Community TransitionOne-time community transition up to $3,000 (transition period up to six months) for ages 18–20

Family Therapy & In-Home Family SupportUp to 8 units per day; telehealth allowed up to 50% of annual services with justification

Peer Parent SupportUp to 8 units per week; telehealth allowed up to 50% of annual services

RespiteIn-home respite up to 24 calendar days per year combined with out-of-home respite; respite subject to EVV

Per-service telehealth allowances

In-Home Family SupportTelehealth allowed up to 50% of annual services (H0004-HA)

Wraparound FacilitationTelehealth allowed up to 50% of annual services (T1016-HA)

Peer Parent SupportTelehealth allowed up to 50% of annual services (H0038-HA)

Family TherapyTelehealth allowed up to 50% of annual services (H0004-HOHA)

Independent Living/Skills BuildingTelehealth allowed up to 25% of annual services (H2033-HA)

BASC score threshold for medical eligibility

BASC thresholdBASC T-score threshold for medical eligibility: 60

Use in eligibilityBASC elevations (T>60 on two+ clinical scales) support the CAFAS/PECFAS functional impairment criterion

Documentary supportBASC results must be included in the Independent Evaluation and supporting documentation

Dollar-limited services per plan of care year

Assistive equipment limitUp to $1,000 per Plan of Care year (combined with specialized therapy)

Community transition limitUp to $3,000 one-time for ages 18–20

Summary of dollar-limited servicesCertain services have plan-year dollar limits and require prior authorization and specified documentation

No coding thresholds present

Coding thresholds absentNo coding thresholds are specified in this extract

Codes referenced separatelyProcedure codes and service limits are documented elsewhere in Chapter 502 and code tables

Billing implicationProviders must follow code-specific documentation and prior authorization rules even though no universal coding threshold is stated

N/A

N/ANot applicable in this extract

NotePlaceholder block — no specific thresholds or definitions provided

N/A

N/ANot applicable in this extract

NotePlaceholder block — no specific thresholds or definitions provided

Provider Responsibilities, Authorizations, and Billing Rules

Prior Authorization

Obtain prior authorization before providing services

Providers rendering services that require prior authorization must receive authorization before rendering all services. Prior authorization does not guarantee payment for services rendered.

Documentation Required

Use EVV for specified services and ensure staff NPI

EVV is required for Out-of-home respite and Independent living/skills building; staff providing EVV must check in/out via the EVV system and obtain an individual NPI to use EVV.

EVV documents individual, service type, date, location, provider, and start/end times.
Child/adolescent or guardian must verify the service at the end of the visit.

Documentation Required

Maintain documentation and evidence of HIPAA compliance

Providers must maintain required documentation and retain all required records for at least five years and provide evidence of HIPAA compliance to BMS upon request; failure to provide documentation may result in disallowance and recovery of payments.

Records must include demographics, Plan of Care with time/date stamp, service details, start/stop times, and provider signature/credential.
Documentation must be provided to authorized BMS personnel or contracted agent upon request.

Denial Risk

Respond to ASO reviews and submit CAP within 30 days

Respond to ASO provider reviews and submit a completed corrective action plan (CAP) electronically within 30 calendar days when required; failure to submit an approved CAP may result in a hold on payments.

ASO will provide a draft exit report and draft CAP within two weeks of exit summation.
CAP must describe corrective steps, prevention systems, monitoring, target completion date, and any training needs.

Note

ASO schedules assessments and transmits IE reports to MECA

The ASO time/date stamps applications, contacts applicants and schedules Independent Evaluations, assists with CAFAS/PECFAS and Freedom of Choice forms, and sends the IE to MECA; the IE must be sent to MECA within 14 calendar days and MECA makes a determination within seven days.

ASO assists applicants with CAFAS/PECFAS and provides the Freedom of Choice form (WV-BMS-CSED-02).
If an IE cannot complete a report within 14 days, ASO will assist in scheduling another IE.

Note

MCO notifies wraparound agency; providers may reject limited referrals

When the MCO assigns a slot, the MCO will notify the wraparound facilitation agency; wraparound facilitation providers may reject referrals only for specified reasons such as error, verified max capacity, or inability to meet needs.

MCO works with family to select a wraparound facilitation agency and contacts the provider to assign a facilitator.
Provider rejection allowed if received in error, at verified maximum capacity, or unable to meet medical/behavioral needs.

Prior Authorization

Accept or reject referrals only for specified reasons

The MCO will send the referral to the chosen wraparound facilitation provider; the provider may reject the referral only if it was received in error, the provider is at maximum verified capacity, or the provider cannot meet the member's current medical/behavioral needs.

Documentation Required

Document CFT invitations, minutes, notes, and submit Plan of Care updates

The wraparound facilitator must document invitations, meeting minutes, case notes, Plan of Care updates, and attempts to obtain feedback/signatures from providers unable to attend; updated Plan of Care must be provided to the MCO within 14 calendar days and signoffs obtained within 10 business days.

Document invitations and all attempts to include service providers.
Provide updated Plan of Care to MCO within 14 calendar days of the meeting.

Billing Rule

Only wraparound facilitator may bill for Plan of Care and CFT activities

Only the wraparound facilitator may bill for Plan of Care meetings, coordination, annual reassessment, six-month progress review, redetermination meetings, and gathering updates from providers; other providers may not bill for participation.

Documentation Required

Notify MCO and submit Transfer form WV-BMS-CSED-15 promptly

The wraparound facilitator must notify the MCO of a provider transfer within two business days and submit the Transfer form (WV-BMS-CSED-15) to the MCO within seven calendar days; the transfer-from agency must send the Plan of Care to the transfer-to agency within 14 calendar days and include the last date of service on the transfer form.

Transfer form (WV-BMS-CSED-15) must include the last date of service.
Transferring agency must maintain the full medical file and continue services until transfer completion.

Prior Authorization

Do not perform or bill PA-required services without prior approval

Providers rendering services that require prior authorization must receive authorization before rendering services and before billing; prior authorization does not guarantee payment.

Documentation Required

Include last date of service on Transfer form and provide full medical file

The transferring agency must submit the Transfer form (WVBMS-CSED-15) including the last date of service to notify the MCO and must have the full medical file current with all Plan of Care updates prior to completing transfer.

Documentation Required

Obtain authorization and include Independent Living in Plan of Care; follow telehealth/EVV rules

Independent living/skills building requires an approved authorization dated prior to initiation, must be included in the Plan of Care, and is subject to EVV; telehealth is allowed for up to 25% of annual services with a telehealth backup plan documented in the Plan of Care.

Service notes required for each instance with provider, date, start/stop times, service code, and signature/credential.
Recipients must be 15–20 years of age to access this service.

Documentation Required

Get authorization and document each Job Development instance

Job development requires an approved authorization dated prior to initiation, must be included in the Plan of Care, and a service note is required for each instance describing the activity, provider, date, times, code, and signature/credential.

Documentation Required

Secure prior authorization and record service notes for employment and specialized therapy

Supported employment and specialized therapy require an approved authorization dated prior to initiation, inclusion in the Plan of Care, and a service note for each instance; specialized therapy is limited to $1,000 per Plan of Care year (combined with assistive equipment).

Prior Authorization

Prior authorize services and submit funding requests for purchases

Services require MCO prior authorization and must be included in the Plan of Care; community transition and assistive equipment require funding requests and MCO approval before purchase, and requests are submitted/invoiced by the wraparound facilitator.

Wraparound facilitation completes funding requests and ensures items do not exceed $3,000 for community transition.
Assistive equipment purchases must be documented with dated itemized receipts and prior authorized.

Prior Authorization

Verify PA exceptions in ProPat for listed services

Certain services (e.g., T1016-HA Wraparound Facilitation, H0004-HOHA Family Therapy, H0004-HA In-Home Support, A1060-HA Non-Medical Transportation, H0038-HA Peer Parent Support) do not require prior authorization per policy; providers should verify coverage and PA requirements using ProPat.

Use ProPat to confirm whether a service requires prior authorization in the system.

Prior Authorization

Ensure prior approval before performing, billing, or expecting payment

Prior Authorization is defined as prior approval necessary for specified services; providers must ensure prior approval is obtained before services are performed, billed, and paid.

Billing Rule

Submit accurate claims and certify per Provider Enrollment Agreement

Claims must be submitted on the designated form or electronically to the fiscal agent with required information; by signing the Provider Enrollment Agreement providers certify claim accuracy and claims must be filed within 365 calendar days from the date of service.

Claims may be endorsed with computer-generated, manual, or stamped signatures as certification.
Separate claim required for each individual child/adolescent.

Billing Rule

Adhere to 365-day timely filing and MCO activation rules

File claims within 365 calendar days from the date of service; BMS will not reimburse claims filed after this timely-filing window, and no Medicaid-reimbursed CSEDW services may be provided until the child/adolescent has been activated with the MCO.

Documentation Required

Complete initial Plan of Care within seven days of enrollment

An initial case plan (initial Plan of Care) must be completed within seven calendar days of waiver enrollment as part of the Seven-Day CFT meeting; this clarifies prior authorization and documentation requirements for the initial plan.

Documentation Required

Follow new service-specific authorization and documentation rules

Added documentation and authorization requirements apply to Independent Living/Skills Building, Job Development, Supported Employment, and Specialized Therapy, including approved authorization dated prior to initiation and service notes for each instance.

Note

Note administrative reorganization of enrollment/section titles

Section titles were reorganized to label Enrollment (502.15) and related subsections such as Slot Allocation and Choice of Single Wraparound Facilitation Provider; providers should note administrative section renaming for reference.

Note

Use updated Chapter 502 section and subsection titles

Multiple Chapter 502 subsection titles were revised (e.g., 502.15 → Enrollment; 502.15.1 → Slot Allocation; 502.15.2 → Choice of Single Wraparound Facilitation Provider); providers should use the updated section titles when locating rules.

Note

Follow updated headings for provider selection and slot allocation

Section 502.15.2 was retitled 'Choice of Single Wraparound Facilitation Provider' and 502.15.1 retitled 'Slot Allocation'; providers should follow the administrative guidance related to provider selection and slot management under these updated headings.

Definitions, Templates, and Appendices

CSEDW — definition

Program nameChildren with Serious Emotional Disorder Waiver (CSEDW)

AuthorityMedicaid HCBS waiver under §1915(c)

Target populationChildren/adolescents ages 3 through 20 (up to 21st birthday per revisions)

NWIC model

ModelNational Wraparound Implementation Center (NWIC) model — strengths-based, family-centered, person-centered wraparound process guided by 10 principles

Planning approachPerson-centered Plans of Care developed in partnership with child/adolescent and family/legal guardian

Team compositionChild/Family Team (CFT) includes family, wraparound facilitator, providers, and community supports

Abuse/Neglect/Exploitation; Critical vs Non-critical Incidents

Critical incidentsIncidents that pose immediate risk to health/safety requiring in-depth investigation (includes suspected abuse/neglect/exploitation)

Non-critical reportable eventsUnusual events/injuries of unknown origin needing recording and analysis for risk management (no immediate CPS/EMS response)

Non-reportable eventsEvents unlikely to impact health/safety that do not require reporting; mandated reporters should use judgment

CSEDW Applicant — eligibility reference

Applicant requirementApplicants must meet CSEDW medical eligibility and be ages 3–20

Residency and MedicaidMust be WV resident and apply for or be enrolled in WV Medicaid at time of eligibility; 217 Group can allow enrollment when financial eligibility not met

Service choice and enrollmentMust choose HCBS over institutional services and enroll with identified MCO; choose CSEDW over ACT when applicable

HIPAA documentation

HIPAA complianceProviders must comply with HIPAA and provide evidence/documentation of compliance to BMS upon request; form of evidence at BMS discretion

ReferenceSee Chapter 300 for additional HIPAA information

Eligible diagnosis

Eligible diagnosisDiagnosable mental, behavioral, or emotional disorder meeting current DSM criteria (excludes V codes, substance use, and developmental disorders unless co-occurring)

Functional impairment requiredImpairment must be due to an eligible diagnosis and demonstrated via assessments

Substantial impairment

CAFAS/PECFAS criterionYouth Total score of 90 or above required for substantial impairment

BASC supportBASC T-scores >60 on two or more clinical scales must support impairment

DocumentationNarrative descriptions and supporting records must corroborate scores

Imminent risk of PRTF placement

PRTF placement indicatorsResided in a PRTF within past six months, reasonable indication of placement within 30 days, or imminent risk of harm due to behaviors

Level of Care requirementApplicant must require a PRTF Level of Care as defined by 42 CFR §440.160

Anchor date

Anchor date definitionAnnual date assigned by the ASO by which medical eligibility must be redetermined (first day of month following initial eligibility establishment)

UseAnchor date triggers annual redetermination and scheduling of reassessments up to 90 days prior

CANS (short)

CANS purposePerson-centered functional needs assessment informing the Plan of Care and CFT about needs, strengths, interests, and natural supports

TimingCompleted by wraparound facilitator within 30 days of assignment and entered into the system within 3 calendar days

CANS — full description and timing

CANS full descriptionCANS is a person-centered, consensus-based functional needs assessment used to inform wraparound facilitation and the CFT

Completion timelineCompleted within 30 days of assignment and entered into system within 3 calendar days

Initial Plan of Care

Initial Plan timeframeInitial Plan of Care must be completed within seven calendar days of CSEDW enrollment assignment

ContentsIncludes interim services, immediate interventions, initial crisis plan, and date for master Plan if not completed

SignaturesRequires signatures of child/adolescent/family, wraparound facilitator, and participants with credentials and timestamps

Master Plan of Care

Master Plan timeframeMaster Plan of Care developed within 30 calendar days of enrollment (unless done at 7-day meeting)

Required elementsGoals, therapy plan, crisis plan, family story, assessments, objectives, interventions, responsible individuals, discharge criteria, transition plan for adolescents over 15

Signatures and reviewMust include signatures with credentials and timestamps and a review date for ongoing updates

Wraparound facilitation — role

Role summaryWraparound facilitation engages child/family in shared decision-making, coordinates supports, leads CFT through engagement, plan development, implementation, and transition

RestrictionsWraparound facilitator and employing agency cannot provide other waiver or State Plan services for the child/adolescent without BMS exception

Documentation responsibilitiesMaintains individual clinical record, documents contacts, Plan of Care updates, and required progress notes for billed activities

Child/Adolescent Acuity Levels

Acuity tiersTwo acuity levels: Moderate (CAFAS/PECFAS 90-130) and High (140+)

ImplicationsAcuity determines PMPM rate and required contact and face-to-face frequencies

Contact expectationsModerate: biweekly contacts and min monthly face-to-face; High: weekly contacts and min two monthly face-to-face

Independent living/skills building (day habilitation)

DefinitionIndependent living/skills building (day habilitation) — community-based activities to build self-help, socialization, and daily living skills aligned to Plan of Care goals

AgeRecipients must be 15–20 years of age to access this service

Telehealth and documentationTelehealth allowed up to 25% annually; approved authorization and service note required for each instance

Job development (prevocational services)

DefinitionJob development (prevocational services) — learning and work experiences to develop employability skills, typically ≤ one year

AgeRecipients must be 15–20 years of age to access this service

Service limitPart of combined weekly cap up to 160 units when combined with related services

Supported employment, individual

DefinitionSupported employment, individual — ongoing individualized supports to obtain and maintain paid employment in integrated settings at or above minimum wage

AgeRecipients must be 18–20 years of age to access supported employment

ComponentsMay include job coaching, placement, planning, transportation, and other workplace supports; documentation of referrals required

Specialized therapy (extended professional services)

DefinitionSpecialized therapy (extended professional services) — activity therapies (music, art, play) directed by trained professionals to address treatment needs

Service limitUp to $1,000 per Plan of Care year combined with assistive equipment

DocumentationMust show progress toward goals; plan must identify sequential steps and measurable objectives

Assistive Equipment

DefinitionAssistive equipment — items to increase, maintain, or improve functional capabilities tied to Plan of Care and medical necessity

LimitUp to $1,000 per Plan of Care year combined with specialized therapy; must be purchased from established business and documented by itemized receipt

Community Transition

DefinitionCommunity Transition — non-recurring set-up expenses for young adults (18–20) transitioning to private residence (one-time up to $3,000)

ExclusionsCannot be used for room/board, routine home maintenance, medications, vehicle expenses, internet, pet care, groceries, etc.

Family Therapy

DefinitionFamily Therapy — counseling/training for child/adolescent and family/legal guardian by qualified mental health professionals

Service limitUp to 8 units per day; telehealth allowed up to 50% of annual services

Staff credentialsLicensed clinicians (psychologist, LPC, LSW, LICSW, etc.) required

In-Home Family Support

DefinitionIn-Home Family Support — bachelor’s-level staff provide coaching to implement therapist-introduced coping strategies

Service limitUp to 8 units per day; telehealth allowed up to 50% of annual services

DocumentationApproved authorization dated prior to initiation and service note for each instance required

Peer Parent Support

DefinitionPeer Parent Support — non-clinical support by someone with lived experience focused on empowerment and advocacy

Telehealth & limitsTelehealth allowed up to 50% of annual services; up to 8 units/week service limit noted elsewhere

Certification changePeer Parent certification requirement was removed (policy update)

Respite Care (In-Home) — definition and EVV note

Respite (In-Home) definitionTemporary relief to caregivers with necessary care provided; subject to EVV; not available to children in foster care/facility/independent living

Service limitsCombined in-home and out-of-home respite up to 24 calendar days per year

Staffing and documentationStaff require HS diploma/GED; service note for each day and approved authorization prior to initiation; use Progress Note form WV-BMS-CSED-07

Respite care — broader definition and limits

Respite definitionTemporary relief to family/legal guardian including necessary care the usual caregiver would provide; can support age-appropriate community activities

Eligibility exclusionsNot provided while child is asleep; foster parents/homes excluded under waiver

DocumentationService notes and prior authorization required; subject to EVV for in-home respite

Transportation (CSEDW)

Transportation definitionService to transport to/from local public community locations for Plan of Care services; billed per mile (A0160-HA)

Service limitUp to 800 miles per month

Provider restrictionFoster families cannot be reimbursed for transportation (duplication of Title IV-E)

ASO — role

ASO roleAdministrative Service Organization acts as BMS agent to screen applicants, schedule IEs, and facilitate evaluations and redeterminations

TimelinesASO time/date stamps applications, contacts applicants within 72 hours, assists with CAFAS/PECFAS and Freedom of Choice forms

Assignment Date / Wraparound initiation

Assignment dateDate the child/adolescent is assigned to the wraparound facilitation agency by the MCO; agency must initiate services within 72 hours

UseTriggers timelines for initial Plan of Care completion and CANS completion

Independent Evaluator

Independent Evaluator (IE)A WV licensed Medicaid provider from the IEN trained by MECA to perform comprehensive, independent evaluations for medical eligibility

DeliverableIE submits Independent Evaluation Report including BASC and other instruments to MECA for eligibility determination

Prior Authorization — definition

Prior Authorization definitionPrior approval required for specified services to be delivered by a specified provider before services can be performed, billed, and paid

Process noteProviders must ensure PAs are obtained and services are included in the Plan of Care; some services referenced as exceptions do not require PA in system

Master plan of care template

Master Plan templateAppendix B: Master plan of care template

PurposeStandardizes master Plan of Care documentation across enrollments

Initial plan of care template

Initial Plan templateAppendix A: Initial plan of care template

UseSupports completion of initial Plan within 7 calendar days of assignment

Children with Serious Emotional Disorder Waiver — short ref

Short referenceChildren with Serious Emotional Disorder Waiver (CSEDW)

Chapter updatesMultiple section titles and subsections were reorganized and renamed (e.g., Enrollment, Slot Allocation, Choice of Single Wraparound Facilitation Provider)

Enrollment — new label for 502.15

Enrollment labelSection 502.15 retitled to 'Enrollment'

ContextPart of broader reorganization of Chapter 502 headings and subsection titles

Slot Allocation — new label for 502.15.1

Slot Allocation labelSection 502.15.1 retitled to 'Slot Allocation'

UseClarifies referral, waitlist, and slot assignment processes

Choice of Single Wraparound Facilitation Provider — new label for 502.15.2

Choice of provider labelSection 502.15.2 retitled to 'Choice of Single Wraparound Facilitation Provider'

ImplicationFormalizes freedom of choice process using WV-BMS-CSED-02 form

Medical Redetermination Eligibility/Appeals

Medical redetermination referenceMedical Redetermination Eligibility/Appeals referenced as section 502.16.1

Appeals linkageIncludes Notice of Decision, Request for Hearing, and timelines for continuing services during appeal

Person-centered Plan of Care

Person-centered Plan of CareUpdated language in section 502.17 to emphasize person-centered Plan of Care

Templates addedAppendices A and B added to standardize Plan of Care documentation

Choice of Single Wraparound Facilitation Provider — section title

Choice of Single Wraparound Facilitation ProviderTitle assigned to section 502.15.2 formalizing provider choice

Related sectionsAssociated with Enrollment, Slot Allocation, and member rights subsections

Policy Changes and Effective Dates

2024-10-01chapter_effective_dateLatest

Chapter 502 (CSEDW) published with reorganized sections, added appendices (Initial and Master Plan of Care templates), telehealth guidance, CFT meeting cadence changes, and removal of mobile crisis to SPA; document header effective date set to 2024-10-01.

2024-10-01timely_filing_requirement

Claims must be filed within 365 calendar days from date of service; BMS will not reimburse CSEDW providers for late claims and services cannot be provided until the member is activated with the MCO.

2024-10-01assessment_threshold_change

BASC functionality threshold for medical eligibility was revised from 70 to 60.

2024-10-01plan_of_care_update

Initial case plan requirement added: complete initial case plan within seven days of waiver enrollment and clarified Plan of Care components, attendees, prior authorization and documentation rules.

2024-10-01evv_addition

Electronic Visit Verification (EVV) requirements were added or clarified for wraparound facilitation and specified services (e.g., independent living/skills building, respite).

2024-10-01billing_clarification

Clarified billing rules for wraparound facilitation and other CSEDW services, and added telehealth billing clarifications and utilization limits.

2024-10-01service_reassignment

Mobile crisis was removed from the waiver chapter and designated as a State Plan Amendment (SPA) service effective 2024-01-01.

2021-07-01prior_updates

Chapter updated previously (effective July 1, 2021) to revise language (e.g., replace case management with wraparound facilitation), add EVV implementation timeline, and update contractual responsibilities and provider requirements.

2020-02-01initial_chapter_issue

Initial Chapter 502 published (effective February 1, 2020) establishing the Children with Serious Emotional Disorder Waiver chapter and foundational policies referenced in later updates.