West Virginia - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In West Virginia, Case Management Services (often referred to as Targeted Case Management or Waiver Care Coordination) are critical components of the state's Medicaid Home and Community-Based Services (HCBS) programs, including the Intellectual/Developmental Disabilities Waiver (IDDW), Aged and Disabled Waiver (ADW), and Traumatic Brain Injury Waiver (TBIW). Case managers serve as the central hub for assessing member needs, developing Person-Centered Service Plans (PCSPs), and monitoring the health, safety, and service utilization of vulnerable residents.

The single biggest structural barrier to entry for prospective case management providers in West Virginia is the strict federal and state Conflict of Interest (COI) firewall mandated by the CMS HCBS Settings Final Rule. An agency cannot be approved to provide case management services to an individual if that same agency provides direct care services (such as residential support or personal care) to that individual. Providers must establish completely independent operational structures or choose to operate exclusively as a case management agency to pass the state's readiness review.

1. Service Definition and Scope

West Virginia defines Case Management Services under the Bureau for Medical Services (BMS) Provider Manual (Chapters 513, 523, and specific waiver chapters) as services that assist eligible individuals in gaining access to needed medical, social, educational, and other services. The case manager acts as an independent advocate and coordinator, ensuring that the waiver participant lives in the least restrictive environment possible.

The scope of work is heavily focused on continuous assessment and person-centered planning. Case managers do not provide direct hands-on care; instead, they facilitate the network of care, monitor the effectiveness of authorized services, and intervene during crises to adjust the service package as the participant's needs change.

• Functional Assessment: Conducting comprehensive evaluations of the participant's medical, behavioral, and social needs.
• PCSP Development: Facilitating the team process to create and update the annual Person-Centered Service Plan.
• Service Coordination: Linking participants to appropriate Medicaid-funded and community-based resources.
• Quality Monitoring: Conducting required monthly or quarterly contacts (in-person and remote) to verify service delivery and participant safety.
• Crisis Intervention: Navigating emergencies, resolving service gaps, and submitting expedited plan modifications to the utilization management contractor.

2. Regulatory and Oversight Agencies

The administration of Medicaid HCBS waivers in West Virginia is a collaborative effort between state departments and contracted vendors. The overarching authority is the West Virginia Department of Human Services (DoHS), which houses the state Medicaid agency.

Day-to-day oversight, provider enrollment, and utilization management are delegated to specific bureaus and contracted entities, which enforce compliance through annual audits, readiness reviews, and claims processing.

• West Virginia Department of Human Services (DoHS): The top-level state agency overseeing public assistance and health programs (https://dhhr.wv.gov/).
• Bureau for Medical Services (BMS): The designated state Medicaid agency responsible for provider policy, manual updates, and final enrollment approval (https://bms.wv.gov/).
• Acentra Health: The state's Administrative Services Organization (ASO) and utilization management contractor that approves PCSPs and conducts provider readiness reviews (https://wvaso.acentra.com/).
• Gainwell Technologies: The fiscal agent operating the West Virginia Medicaid Management Information System (WVMMIS) and Provider Enrollment Application portal (https://www.wvmmis.com/).
• WV CARES: The state unit within the Office of Health Facility Licensure and Certification (OHFLAC) responsible for processing mandatory fingerprint-based background checks (https://ohflac.wvdhhr.org/wvcares/).

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia genuinely does not require a Certificate of Need (CON) for case management agencies, nor is access restricted by a closed network, moratorium, or competitive Request for Proposals (RFP) procurement. The state operates an open enrollment model for qualified Medicaid providers.

However, there are strict structural preconditions that will block an application before it is accepted. The most significant is the Conflict of Interest (COI) mandate, which requires absolute separation between case management and direct service provision. Additionally, applicants must pass a comprehensive readiness review by the state's ASO before they are permitted to bill.

• Conflict of Interest Firewall: The applicant must structurally demonstrate they will not provide direct waiver services (e.g., personal care, residential habilitation) to the same individuals receiving their case management services.
• Business Registration: The entity must be actively registered and in good standing with the West Virginia Secretary of State before initiating Medicaid enrollment.
• NPI Requirement: The agency must possess a Type 2 (Organizational) National Provider Identifier (NPI) that matches the specific case management taxonomy codes required by BMS.
• Readiness Review Approval: Before an application is finalized, the agency must pass a pre-enrollment readiness review conducted by BMS and Acentra Health to validate their Policy & Procedure Manual.

4. Licensure and Certification Requirements

West Virginia does not issue a distinct "facility license" for Case Management Agencies through the Office of Health Facility Licensure and Certification (OHFLAC). Because case management is an administrative and coordinative service rather than a clinical facility service, it falls outside traditional OHFLAC facility licensure.

Instead, providers are approved through a direct certification and enrollment process managed by the Bureau for Medical Services (BMS). To achieve this certification, agencies must prove compliance with Chapter 300 (Provider Participation Requirements) and the specific waiver chapters (e.g., Chapter 513 for IDDW) by submitting a comprehensive operational manual.

• Licensure Exemption: No OHFLAC facility license is required to operate a standalone case management agency in West Virginia.
• BMS Certification: Provider approval is granted directly via the Medicaid enrollment and ASO readiness review process.
• Policy Manual Submission: Applicants must submit a Case Management Policy & Procedure Manual detailing PCSP development, grievance procedures, and COI mitigation.
• Insurance Requirements: Agencies must maintain and provide proof of commercial general liability insurance, professional liability (errors and omissions), and employee fidelity bonding.

5. Medicaid Provider Enrollment

All prospective case management agencies must enroll through the West Virginia Medicaid Management Information System (WVMMIS), operated by Gainwell Technologies. The process is entirely electronic via the Provider Enrollment Application (PEA) portal.

Providers must complete the application within a specific timeframe once started and must agree to the terms outlined in the West Virginia Medicaid Provider Agreement. Enrollment must be revalidated every five years.

• Enrollment Portal: Applications must be submitted through the Gainwell Technologies PEA portal at https://www.wvmmis.com/.
• Application Window: Providers have exactly 120 days from the date of initiating the enrollment application in the PEA portal to complete and submit it.
• Application Fee: Agencies are subject to the federal ACA institutional provider application fee (approximately $731 for 2024) unless they have already paid it to Medicare or another state's Medicaid program.
• Provider Agreement: Applicants must sign the BMS Provider Agreement, legally binding the agency to Chapter 300 participation requirements and state billing rules.

6. Staffing, Training and Background Checks

West Virginia enforces strict educational and background requirements for individuals employed as case managers. Agencies must verify these credentials prior to allowing staff to bill for services.

All staff must clear the West Virginia Clearance for Access: Registry and Employment Screening (WV CARES) system, which is a comprehensive, fingerprint-based state and federal background check.

• Background Checks: Mandatory fingerprint-based criminal background checks and registry screenings must be completed through WV CARES for all case managers.
• Education Minimums: Case managers must hold a Bachelor's degree in a human services field (e.g., psychology, sociology, social work), or be a licensed registered nurse (RN) or licensed social worker (LCSW).
• Required Training: Staff must complete state-mandated care coordination and person-centered planning training prior to independently managing a caseload.
• Supervision: The agency must designate a qualified program administrator or clinical supervisor to oversee case management staff and review PCSPs.

7. Documentation, Policies and Records

The Bureau for Medical Services requires meticulous documentation to justify the billing of case management units. The core of this documentation is the Person-Centered Service Plan (PCSP) and the ongoing contact logs.

Agencies are subject to annual 10% sample reviews by Acentra Health to ensure that documentation aligns with the CMS HCBS Settings Final Rule and state manual requirements.

• PCSP Standards: Service plans must be updated at least annually, or immediately following a significant change in the participant's condition.
• Contact Logs: Case managers must maintain detailed monthly and quarterly progress notes verifying that authorized services are being delivered and goals are being met.
• Freedom of Choice: Agencies must maintain signed documentation proving the participant was offered a totally uncoerced choice of waiver service providers.
• Incident Reporting: Critical incidents must be documented and reported to Acentra Health within state-mandated timeframes (typically 24 hours).
• Record Retention: All clinical and billing records must be retained for a minimum of five years and made available to BMS or Acentra Health upon request.

8. Billing, Rates and Claims

Case management services are billed on a fee-for-service basis through the Gainwell Technologies Health PAS-Online portal. Rates are standardized and published on the BMS fee schedule.

Services must be prior-authorized by Acentra Health based on the approved PCSP before any claims will be paid by the MMIS.

• Billing Code: Services are typically billed using Healthcare Common Procedure Coding System (HCPCS) code T1017 (Targeted Case Management).
• Unit Measurement: Case management units are tracked and billed in 15-minute fractional increments.
• Prior Authorization: No claims will be paid unless the specific units have been prior-authorized by Acentra Health in the participant's PCSP.
• Claim Submission: Claims must be submitted electronically via the Gainwell Health PAS-Online portal within 365 days of the date of service.

9. Approval Sequence and Timeline

Becoming a fully approved case management agency in West Virginia is a multi-step process that typically takes 2 to 4 months from initial business registration to active billing status.

Delays most commonly occur during the WV CARES background check phase or if the submitted Policy & Procedure Manual requires multiple revisions during the Acentra Health readiness review.

• Step 1: Register the business entity with the WV Secretary of State and obtain a Type 2 NPI and EIN (Weeks 1-2).
• Step 2: Establish a WV CARES account and process initial staff fingerprint background checks (Weeks 3-5).
• Step 3: Submit the Medicaid Provider Enrollment Application via the Gainwell PEA portal (Weeks 4-6).
• Step 4: Undergo the BMS and Acentra Health readiness review, including Policy & Procedure Manual approval (Weeks 6-10).
• Step 5: Receive final Medicaid activation, gain access to the Health PAS-Online portal, and begin accepting referrals (Weeks 10-12).

10. Common Denials and Survey Findings

During annual audits conducted by Acentra Health or BMS designees, case management agencies frequently face recoupments or corrective action plans due to administrative and documentation errors.

Maintaining strict adherence to timelines for PCSP renewals and monthly contacts is the most critical factor in surviving a state audit.

• COI Violations: Findings where an agency failed to maintain a clear operational firewall between case management and direct service provision.
• Expired PCSPs: Billing for case management services during a period where the participant's annual service plan had lapsed.
• Missing Contacts: Failure to document required monthly or quarterly monitoring visits, leading to immediate recoupment of billed units.
• Inadequate Progress Notes: Submitting contact logs that are generic, repetitive, or fail to address the specific goals outlined in the PCSP.

11. Key Contacts and Resources

Prospective providers should rely exclusively on official state portals and manuals when preparing their applications. The Bureau for Medical Services and its contracted vendors provide all necessary documentation online.

It is highly recommended to review Chapter 300 and the specific waiver chapters (e.g., Chapter 513 for IDDW) in the BMS Provider Manual before initiating enrollment.

• WV Bureau for Medical Services (BMS): Official Medicaid policy, provider manuals, and fee schedules (https://bms.wv.gov/).
• Gainwell Technologies (WVMMIS): Provider enrollment portal, PEA user guides, and claims submission (https://www.wvmmis.com/).
• Acentra Health (WV ASO): Utilization management, readiness reviews, and PCSP prior authorizations (https://wvaso.acentra.com/).
• WV CARES: Mandatory background check system registration and processing (https://ohflac.wvdhhr.org/wvcares/).

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