Medical Online Prior Authorization
Submission Implementation
As you may be aware IRG d/b/a APS Healthcare, Inc. (APS) is now the primary Utilization Management Contractor (UMC) for prior authorization of Medicaid medical and behavioral health services.
In order to improve the efficiency and timeliness of processing medical prior authorization requests, APS has developed web-based complete CareConnection (C3) software system for the direct data entry of West Virginia Medicaid prior authorization requests.
To carry out the requirements for prior authorization of medical services, APS has contracted with the West Virginia Medical Institute (WVMI) to continue the medical necessity review of prior authorization requests. This involves the review of services requiring prior authorization in the following areas:
- General and Acute Hospital Services
- Inpatient Rehabilitation <21 members
- Outpatient Surgery
- Physician Services requiring PA
- Orthodontic Services
- Dental and Oral Health Services
- Vision Services
- Physical and Occupational Therapy Services
- Speech and audiology Services
- Cardiac Rehabilitation Services
- Pulmonary Rehabilitation Services
- Orthotic and Prosthetic Services
- Durable Medical Equipment
- Radiology and Imaging Services
- Laboratory Service
- Home Health Services
- Hospice Services
- Private Duty Nursing Services <21 members
Implementation of the system will be phased in by review area. Upon implementation of the system, WVMI and providers will begin using the APS complete CareConnection® (C3) to request prior authorization.
Training & Registration/Enrollment information, along with system and policy updates, and user guidelines are accessible below, as well as on the website for WVMI (www.wvmi.org).
Information will continue to be sent out to providers via email and fax as well as posted with the medical trade associations and provider groups correspond with WV medical providers/organizations.
APS will continue to provide technical assistance throughout the entire transition—for immediate assistance you may call 1-800-346-8272 or email wvmedicalservices@apshealthcare.com.
This system will incorporate the current manuals and data requirements in all utilization forms in current use and will include adoption of the InterQual® criteria set in all areas of review where it is available. For review areas where InterQual® is not available, the Bureau for Medical Services has approved review criteria based on the specific Medicaid Chapter requirements that are to be utilized by the UMC. A list of services (including the CPT/HCPCS codes and other relevant information) requiring prior authorization will be available to providers for each review area and will be updated as necessary to facilitate accurate submission of prior authorization requests.
Prior to the implementation of each service type, postings will be made that outlines various policies related to the prior authorization review process. Please take note of these updates and feel free to bookmark them and/or print them for ongoing reference.
For further information or to include your professional organization in our mailings and updates please contact APS Healthcare by calling 1-800-346-8272 or by emailing wvmedicalservices@apshealthcare.com.
 Medical UM Provider Registration
Providers: Effective Tuesday, August 2, 2011, WVMI will utilize the 2011 update of the InterQual criteria, where InterQual criteria has been used, i.e., Inpatient Hospital Admissions, Outpatient surgery, DME, and Imaging. If you have any questions or want to inquire about Smart Sheets please go to WVMI’s website: www.wvmi.org
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