Prior authorization required for infusion and IHPT

Drugs used for home infusion therapy and all In-Home Parenteral Therapy (IHPT) services require prior authorization and must be requested through the BMS-designated pharmacy prior authorization vendor; the request must justify the need and, for infusion drugs, explain why oral therapy is unsuitable.

• Requests must be made through the pharmacy prior authorization vendor using approved Prior Authorization Forms available on the BMS website.

Prior authorization for diabetic supply overages

Prescriptions for diabetic testing supplies or syringes/needles that exceed the stated quantity limits (e.g., 150 test strips/30 days, 200 lancets/30 days for insulin-dependent members) require prior authorization through the pharmacy prior authorization vendor.

• Limits for insulin-dependent members: urine/blood test strips 150/30 days; lancets 200/30 days; insulin syringes 100/30 days; pen needles 100/30 days.
• Requests for quantities greater than these limits must be submitted to the pharmacy prior authorization vendor.

Prior authorization required for IHPT and certain drugs

All IHPT services and certain drugs require prior authorization via the pharmacy prior authorization vendor; prior authorization may be initiated by the dispensing pharmacist, prescriber, or the prescriber's designee and, when complete, will be addressed within 24 hours.

• Signed physician orders for compounded IHPT medications must be provided if compounding reimbursement is requested.
• If complete information is provided, requests will be addressed within 24 hours; emergent 72-hour supplies permitted while PA is pending.

Prospective DUR edit override and cash-payment risk

When a prospective DUR message requires an override, the dispensing pharmacist may need to contact the pharmacy prior authorization vendor Help Desk to obtain an edit override; requests to override edits after service has been rendered will be denied except for retroactive eligibility, and members paying cash to bypass PA/limits may cause Medicaid to deny coverage.

• Pharmacists should use DUR outcome and intervention codes when processing prospective DUR messages and call the prior authorization vendor Help Desk when instructed.
• Medicaid may deny coverage of controlled substances when members pay cash to circumvent prior authorization or quantity limits.

Prior authorization required

Certain drugs and additional supplements (for example, ESRD-related vitamins/minerals) require prior authorization through the Rational Drug Therapy Program (RDTP) or other designated prior authorization pathways; providers must contact the appropriate prior authorization vendor to confirm eligibility or diagnosis.

• For ESRD supplements the prescriber must contact the RDTP by fax, phone, or mail to confirm the ESRD diagnosis.
• Limited Pharmacy Services brand-name drugs with generic equivalents require prior authorization.

Prior authorization subject to standard Medicaid rules

All pharmacy claims are subject to standard Medicaid rules including DUR edits and prior authorization requirements; providers must follow POS electronic submission or approved paper claim procedures and secure any required prior authorizations before rendering services.

• Claims must be filed within 12 months from the date of service and must accurately report NDC, units, days' supply and other required data.
• If the service is provided before PA is obtained, the member should be informed they may be financially responsible.

IHPT Prior Authorization

IHPT drug components and compounding fees require prior authorization through the pharmacy prior authorization vendor; billing and units submitted for payment must match the authorized amount and duration (maximum 34 days) and the vendor issues compounding-fee authorization upon receipt of the signed physician order.

• Units billed must reflect actual vials or milliliters used and must match the prior authorization.
• Do not bill diluent separately if reimbursement for a compounding fee is requested; compounding fee includes supplies and professional services.

Prior authorization vendor

BMS designates a Pharmacy Prior Authorization Vendor to perform prior authorizations for prescription drugs; providers must use that vendor and its approved forms/processes when requesting prior authorization.

• Prior authorization requests may be made by telephone, fax, or mail; Prior Authorization Forms are available on the BMS website.
• It is the responsibility of the prescribing provider or pharmacist to obtain authorization before rendering the service.

PDL non-preferred drug access

Non-preferred drugs on the Preferred Drug List (PDL) remain accessible through the prior authorization process; providers should submit PA requests when non-preferred agents are clinically indicated.

• The PDL and criteria for coverage of non-preferred drugs are available on the BMS website.

Preferred drug list step

When appropriate, providers must try PDL-preferred drugs before non-preferred drugs will be approved; this step requirement is enforced via the prior authorization criteria developed by the DUR/P&T process.

• PDL-preferred drugs are selected by the P&T Committee and the list is updated at least annually.

DUR Board role in PA criteria

The DUR Board assists BMS in defining criteria for drugs that require prior authorization and may thus enable step or coverage rules; providers should refer to BMS criteria informed by the DUR Board when requesting authorization.

• DUR Board meeting agendas and criteria information are available on the BMS website.

Generic-first requirement and brand justification

Formulary drugs must be dispensed in generic form when a generic equivalent is available; dispensing a brand-name product when a generic exists requires justification per the general pharmacy instructions and prior authorization where applicable.

• Brand name use must be justified as referenced in the general pharmacy instructions; brand justification procedures apply when submitting claims.

IHPT prior authorization documentation

Prior authorization requests for IHPT must be submitted through the pharmacy prior authorization vendor using the approved forms posted on the BMS website; signed physician orders for compounded IHPT medications are required when compounding reimbursement is requested.

• Prior Authorization Forms (Form IV-1) must be submitted via fax or mail when required by the vendor.
• The prior approval is effective from the date of the physician's original order and changes in therapy require new prior authorizations.

Required contents for prior authorization requests

Prior authorization requests must include member name/address/Medicaid ID, drug name/strength/dosage/duration, diagnosis, pertinent laboratory information, justification for drug use, return fax number, and the signature of the prescriber or pharmacist.

• Incomplete PA requests may delay the 24-hour turnaround; the provider is responsible for obtaining the authorization before rendering the service.

Annual permit filing requirement

Pharmacies must file a copy of their current West Virginia State Board of Pharmacy permit with BMS annually; failure to have a current license/permit on file will result in non-reimbursement until BMS receives documentation.

• Out-of-state pharmacies shipping into West Virginia must be licensed in their state and hold a WV BOP permit as applicable.

340B claim submission values and denial risk

340B-participating pharmacies must bill each POS claim using either Claim Segment-Submission Clarification Code value '20' (420-DK) OR Pricing Segment- Basis of Cost Determination value '08' (423-DN) to identify 340B claims and must submit actual acquisition costs; using both values together will result in claim denial.

• Submission of invoices may be required for audit and invoices/actual acquisition cost must be available on request.
• Per NCPDP guidance the '20' and '08' values are mutually exclusive; using both leads to denial.

A log of prescriptions returned to stock

A returns-to-stock log of prescriptions filled but not dispensed must be maintained and retained by the pharmacy for five years to support timely reversals and audits; claims must be reversed within 15 days when not dispensed.

• Maintain the returns log for five years for auditing purposes and reverse claims within 15 days of the fill when not dispensed.

Retention of delivery and returns logs (5 years)

Pharmacies must retain delivery signature logs (proof of delivery) and returned-to-stock logs for five years to support reversals or disputes; absence of member signature as definitive proof of delivery may lead to reimbursement being withheld or claim reversal.

• In disputes the only definitive proof of delivery accepted is a copy of the member's signature on the delivery log.
• Recommendation: retain signature logs for five years to support any delivery disputes.

Certain state-funded eligibility requires eligibility letter and paper claim

For state-funded non‑Medicaid programs, providers must have the written eligibility communication/authorization letter and may be required to submit claims on the approved paper claim form with the eligibility letter attached as instructed.

• Examples include letters with prefix codes (e.g., '39', '15', '38') that identify covered services and billing instructions.
• Claims for these programs must follow Medicaid coverage rules and may require paper submission with the authorization letter attached.

Presentation of eligibility for certain state-funded programs

When members present for services under certain state-funded programs (emergency assistance, juvenile services, adult family/protective services), the member must present the eligibility letter at point of service and providers must follow the submission instructions (POS or approved paper form) noted on the letter.

• Letters include identification prefixes (e.g., '17' for juvenile services) and specify whether claims should be submitted online or on paper with the letter attached.

Lost/Stolen Medication Documentation

Pharmacies must retain a copy of the police report when replacing stolen controlled substances; the prescribing practitioner must agree to replace the lost/stolen medication and replacements are limited to one occurrence per drug per year.

• Pharmacy must retain the police report copy for audit purposes.
• Approvals for lost/stolen controlled substances are limited to one occurrence per drug per year.

IHPT compounding fee documentation and unit matching

IHPT compounding fee reimbursement requires submission of a copy of the signed physician order to the pharmacy prior authorization vendor; units billed must match the prior authorization and represent actual vials or milliliters used.

• The compounding fee includes supplies and professional services; do not bill the diluting agent separately if compounding fee reimbursement is requested.
• Units are defined per First Data Bank product classification and must match the amount authorized by the prior authorization vendor.

State Plan references for documentation and billing

Providers should follow the State Plan sections referenced in the chapter for documentation and billing rules governing pharmacy services and pharmacist vaccine administration.

• State Plan sections referenced include reimbursement and vaccine-administration rules; follow those sections when preparing documentation and claims.

Excluded or unenrolled prescribers cause denial

Prescriptions issued by prescribers excluded from federal health programs or by prescribers not enrolled with West Virginia Medicaid will be denied reimbursement; ensure prescribers are enrolled and not excluded before dispensing.

• Verify prescriber enrollment and exclusion status prior to filling to avoid claim denial.

Third‑party vendor PAs and after-the-fact requests will be denied

Prior authorization requests submitted by third‑party vendors or contractors will be denied; prior authorization requests made after the service is rendered will be denied (except for case-by-case consideration with backdated eligibility).

• It is the provider's responsibility (physician or pharmacist) to obtain authorization before rendering the service.
• Backdated/retroactive eligibility cases may be considered on a case-by-case basis.

Edit override requests after service are denied (except retroactive eligibility)

Requests for edit overrides after the service has been rendered are generally denied except in cases of retroactive eligibility; pharmacists should obtain any required override prior to dispensing.

• Use DUR outcome/intervention codes and contact the prior authorization vendor Help Desk when instructed to obtain an override before dispensing.

Do not use both NCPDP values '20' and '08' together

Using both NCPDP 340B identification values '20' (Claim Segment-Submission Clarification Code) and '08' (Pricing Segment- Basis of Cost Determination) together on the same claim is prohibited and will result in denial of the claim.

• Use either '20' OR '08' per NCPDP guidance to identify 340B claims; if a claim is later identified as 340B it must be reversed and rebilled using value '08' only.

Denial risk when member pays cash to bypass PA/limits

Medicaid may deny coverage of controlled substances when the member is found to be paying cash to bypass prior authorization and/or quantity limit requirements; pharmacies are encouraged to report suspected cash-pay circumvention to BMS.

• Report suspected cash payments intended to bypass Medicaid using the Cash Waiver Form available on the BMS website.

Delivery proof (member signature) required to avoid reversals

Pharmacies must maintain proof of delivery (member signature) for shipped medications; in disputes lack of a delivery signature may result in reversal of reimbursement and reimbursement will be withheld when signature proof is not provided.

• Maintain a delivery signature log for five years to support disputes and potential reversals.
• Claims for medications not received by the member may be reversed to allow a local pharmacy to meet member needs.

Claims during incarceration will be denied

Medicaid claims with dates of service during a period of incarceration will be denied; if the member has been released before the restriction is updated, obtain positive identification and contact the prior authorization vendor Help Desk for overrides as instructed.

• Pharmacists must verify incarceration status before dispensing and follow override procedures if applicable.

Denial risks: eligibility, prescriber NPI, and permit issues

Claims may be denied for eligibility problems, incorrect prescriber identification (non-prescribing NPI entities), or provider enrollment/permit issues; ensure valid member eligibility, prescribing NPI, and current pharmacy permit are on file prior to billing.

• Only prescribing NPI entities are permissible on POS claims; claims with non-prescribing NPI entities will be denied.
• Pharmacy payments may be withheld if the current license/permit is not on file with BMS.

Denial for replacements caused by pharmacy/provider error

Requests to replace wasted medications caused by improper storage or delivery by the pharmacy or improper handling by the administrating provider will be denied; replacements due to member improper use/storage may be considered case-by-case.

• Inform members on proper storage and device use; replacements caused by pharmacy/provider error are not payable.

Denial risk for medical residents without educational permit

Effective July 1, 2024, prescriptions submitted by medical residents without a valid educational permit on record with BMS's fiscal/provider enrollment agent will be denied; verify resident permits prior to dispensing.

• Claims submitted by medical residents without a valid educational permit on file will be denied beginning July 1, 2024.

IHPT member must reside in private home or domiciliary care

Members receiving IHPT must reside in a private home or domiciliary care facility; institutional settings such as hospitals, SNFs, ICF/IID group homes, rehabilitation centers, and other institutional settings are not eligible for IHPT.

IHPT covered only in private home/domiciliary settings

IHPT is covered only when the member resides in a private home or domiciliary care setting; institutional settings are excluded from IHPT coverage.

IHPT billing/delivery for home use — PA up to 34 days

IHPT drugs and compounding may be billed and delivered for use at the member’s home under prior authorization for a maximum duration of 34 days per prior authorization.

• Billing shall correspond to therapy for a duration of up to 34 days as prior authorized.

Returned-to-stock log retention — 5 years

Maintain prescription returned-to-stock logs for five years to support audits and timely reversals.

Delivery signature log retention — 5 years

Maintain delivery signature logs for five years to support reversals or disputes; the member signature is the definitive proof of delivery in disputes.

Retain police report for stolen controlled substances

Retain a copy of the police report for stolen controlled substances for audit purposes and ensure the prescribing practitioner agrees to replacement prior to dispensing a replacement.

Signed physician order required for IHPT compounding fee PA

IHPT compounding fee authorization requires submission of a copy of the signed prescribing physician's order to the Pharmacy Prior Authorization Vendor; units billed must exactly match the prior authorization.

Claims denied during incarceration periods

Claims with dates of service during incarceration will be denied; ensure member eligibility status before billing.

Edit override requests after service are generally denied

Requests to override edits after the service has been rendered are generally denied except for retroactive eligibility; obtain necessary overrides prior to dispensing when possible.