Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Provide the date of your request at the top of the form.
3. Fill in the C3 Requesting/Submitting Organization details exactly as registered on C3, including the name, address, and NPI number.
4. Enter the contact information for the person submitting the request, including their name, phone number, fax number, and email address.
5. Complete the referring/ordering provider information. Ensure that this provider is actively enrolled with WV Medicaid. Include their name, NPI number, and contact information.
6. Provide the Place of Service/Servicing Provider details. Also, ensure that this provider is actively enrolled with WV Medicaid.
7. Enter the member's Medicaid number, date of birth, first name, and their address.
8. Select the procedure type: LAB, IMAGING, or RADIOLOGY.
9. Specify the authorization type and include any reasons for retrospective requests if applicable.
10. If the member is under age 21, indicate if this request is an EPSDT referral and provide relevant admission/procedure information.
11. List all relevant ICD diagnosis codes, including primary and additional symptoms.
12. Provide CPT/service codes requested along with the start date for the procedure.
13. Indicate whether physician orders for each code are attached, and if not, provide a reason.
14. Justify the medical necessity, and note if you are attaching supporting documents like H&P or treatment plans.
15. Include information about the current course of treatment, conservative treatment history, and any associated medications, treatments, or previous diagnostic studies.
16. If applicable, answer the cancer diagnosis questions and provide relevant details.
17. Once all fields are completed, save your changes, and choose to download, print, or share the form as necessary.

Complete your WV Medicaid Prior Authorization form online today for a streamlined submission process.