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    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthWest Virginia BMS PRTF Coverage Update | OpenPayer
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    CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

    Psychiatric Residential Treatment Facilities (PRTF) coverage criteria and provider requirements

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    Governs PRTF program requirements, admission/denial processes, staffing, assessment tools, and discharge/continuity requirements for WV Medicaid members and facilities serving them.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyPsychiatric Residential Treatment Facilities (PRTF) coverage criteria and provider requirements
    Policy CodePolicy N/A
    Change TypeClarified and revised assessment and admission requirements
    Effective DateJan 1, 2023
    Last ReviewNov 1, 2022
    Next Review DateN/A
    Key ActionComplete determination of admission within 72 hours of receipt of referral.
    SourceLink
    POLICY UPDATE CHANGES

    Assessment requirements clarified to require completion of assessments (CANS, CAFAS, BASC) and connection to WV assessment pathway for discharge planning.

    Requirement added that assessments must be completed on WV members upon arrival even if they have co-occurring medical diagnoses (e.g., pregnancy, diabetes).

    In-state and out-of-state facilities must follow the same requirements for assessments and discharge plans.

    Effective date updated in response to comment (policy effective date set to 11/01/2022 for internal procedure updates).

    Provider must complete determination of admission within 72 hours of receipt of referral (WV BMS retained language; no change).

    Providers remain responsible to provide written confirmation of denial to DHHR, BMS and BSS when member is in DHHR legal custody.

    Requirement retained that providers review referrals for members with previous denials or prior PRTF treatment rather than immediately denying based on past information.

    Staffing ratio requirement (1:3 day/evening) and use of specific staff mix are retained as policy; commenters requested loosening to 1:6 but no change made.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    72 hoursadmission determination timeframe
    CANS, CAFAS, BASCrequired assessment tools
    1:3staff-to-patient ratio day/evening
    1:6midnight shift ratio (comment)
    11/01/2022referenced internal effective date

    Coverage Criteria and Facility Requirements

    The policy retains the existing staffing ratio requirement of 1:3 during day and evening hours and the specified staff mix (including RN, RTs, MHTs, and teachers). Commenters requested loosening the ratio (for example to 1:6) or aligning it with other residential treatment settings, but the policy decision was to maintain the 1:3 day/evening standard to reflect the higher level of acuity at the PRTF level of care.

    Provider Responsibilities and Operational Requirements

    Prior Authorization

    Complete admission determination within 72 hours

    Determination of admission must be completed within 72 hours of receipt of the referral; providers are responsible to meet this timeframe for each referral they receive.

    Step Therapy

    Review each referral before denying based on prior denials

    Do not deny a new referral solely because the member had a prior denial or prior program failure; each referral must be reviewed on its own merits and the provider must document that review.

    Documentation Required

    Complete and retain CANS, CAFAS, BASC assessments

    Complete and retain required assessment instruments (CANS, CAFAS, BASC) as part of admission, continued-stay, and discharge planning; assessments must be available for use in APR FACTS and discharge pathway planning.

    • Maintain completed CANS, CAFAS and BASC in the member record for admission, continued stay reviews, and discharge planning.
    Documentation Required

    Complete assessments on WV members with medical comorbidity at arrival

    For West Virginia members, complete the required assessments upon arrival even when the member has co-occurring medical diagnoses (for example pregnancy or diabetes); this requirement applies to in-state and out-of-state facilities.

    • Ensure assessments are completed at admission for WV members with co-occurring medical conditions.
    • Apply the same assessment and discharge requirements to in-state and out-of-state facilities.
    Denial Risk

    Serve written denial notice to DHHR (and BMS/BSS when in DHHR custody)

    If the facility denies a referral, the provider must serve written confirmation of the denial to DHHR; when the member is in DHHR legal custody, include BMS and BSS in written notice as required by the facility responsibility.

    • Providers remain responsible for notifying DHHR and, if applicable, BMS and BSS when a denied member is in DHHR legal custody.
    • Failure to provide the required written denial notice may be a compliance issue.
    Denial Risk

    Review referrals with prior denials or prior PRTF stays before denying

    Do not immediately deny referrals solely because the member had prior denials or prior PRTF stays; providers must review such referrals and document the review rather than relying only on past denials recorded in APR FACTS.

    • Review referrals for members with previous denials or prior PRTF treatment and document findings.
    • APR FACTS may record prior denials, but providers must still perform a current referral review.

    Definitions and Assessment Instruments

    Required behavioral assessment instruments
    Required instrumentsChild and Adolescent Needs and Strengths (CANS); Child and Adolescent Functional Assessment Scale (CAFAS); Behavior Assessment System for Children (BASC)
    PurposeStandardized assessment of severity, treatment needs, and to guide discharge planning and linkage to home- and community-based services (HBCS)
    Policy statusRequirement retained by WV BMS; currently mandated by West Virginia law
    Cost considerations notedStakeholders commented that adding CAFAS and BASC increases facility costs since they are not public domain

    Residential Level of Care

    Residential

    Residential level of care criteria (PRTF).

    Admission requirements summary: Determination of admission must be completed within 72 hours of receipt of referral; standardized assessments (CANS, CAFAS, BASC) must be completed and documented upon arrival, including for members with co-occurring medical conditions.

    Assessment and Discharge Planning Requirements

    Assessments completion required at admission and for discharge planning
    Admission determination timeframeDetermination of admission must be completed within 72 hours of receipt of referral
    Assessments at admissionCANS, CAFAS, and BASC must be completed and documented upon arrival for WV members, including those with co-occurring medical diagnoses (e.g., pregnancy, diabetes)
    Use for discharge planningCompleted assessments must be used to plan discharge and connect members to the WV assessment pathway and HBCS when approved
    In-state and out-of-state facilitiesBoth in-state and out-of-state facilities must follow the same requirements for assessments and discharge planning

    Policy Background

    Psychiatric Residential Treatment Facilities (PRTFs) provide intensive behavioral health treatment for youth under age 22 who have higher acuity needs that require a residential level of care. The policy emphasizes use of standardized behavioral assessments to document severity and treatment needs, and to guide discharge planning and linkage to home- and community-based services.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyPsychiatric Residential Treatment Facilities (PRTF) coverage criteria and provider requirements
    Policy CodePolicy N/A
    Change TypeClarified and revised assessment and admission requirements
    Effective DateJan 1, 2023
    Last ReviewNov 1, 2022
    Next Review DateN/A
    Key ActionComplete determination of admission within 72 hours of receipt of referral.
    SourceLink
    On This Page
    Coverage Criteria and Facility RequirementsProvider Responsibilities and Operational RequirementsDefinitions and Assessment InstrumentsResidential Level of CareAssessment and Discharge Planning RequirementsPolicy Background