West Virginia - Physical Therapy Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The West Virginia Department of Human Services (DoHS) Bureau for Medical Services (BMS) covers Physical Therapy under Chapter 515 of the Medicaid manual and through Home and Community-Based Services (HCBS) waivers such as the Aged and Disabled (A/D) Waiver. Services are defined as medically necessary evaluations and treatments addressing mechanical, physiological, and developmental impairments, ordered by a licensed attending physician and furnished by a qualified physical therapist.

Approval to bill West Virginia Medicaid for outpatient or waiver-based physical therapy requires an active, unencumbered license from the West Virginia Board of Physical Therapy before an application can be submitted to the state's Medicaid Management Information System (WVMMIS). Providers must also navigate strict utilization management gates, specifically securing prior authorization from the state's designated medical review contractor before exceeding the hard cap of 20 therapy visits per calendar year.

1. Service Definition and Scope

West Virginia Medicaid defines physical therapy as services provided in an outpatient or community setting to diagnose and treat eligible beneficiaries with movement-related conditions. The scope of practice is governed by W. Va. Code R. § 16-1-8, which authorizes therapists to examine, evaluate, and test patients with functional limitations to determine a treatment intervention plan.

Under Chapter 515 of the BMS manual, covered services include evaluations, re-evaluations, and various therapeutic modalities. Services must be medically necessary and cannot duplicate physical therapy provided through the public school system unless explicitly coordinated and documented.

• Modality: Any physical agent supplied to produce therapeutic changes to biologic tissue, including thermal, acoustic, light, mechanical, or electric charge.
• Physical Therapist: An individual who is a graduate of an approved physical therapy curriculum and licensed by the West Virginia Board of Physical Therapy.
• Physical Therapy Assistant: An Associates of Arts graduate working under the direct supervision of a Physical Therapist and licensed by the state board.
• Service Limit: Medicaid covers up to 20 occupational/physical therapy visits per calendar year without prior authorization, excluding evaluations.
• Non-Covered Settings: WV Medicaid does not cover outpatient PT codes when rendered to an inpatient in a hospital or skilled nursing facility under this specific manual chapter.

2. Regulatory and Oversight Agencies

The West Virginia Bureau for Medical Services (BMS) is the single state agency responsible for administering the Medicaid program, setting coverage policies, and establishing reimbursement rates. BMS oversees the HCBS waivers and the fee-for-service therapy benefits.

The West Virginia Board of Physical Therapy regulates the practice of physical therapy, issuing licenses and enforcing continuing education requirements. Provider enrollment and claims processing are managed through the state's fiscal agent via the WVMMIS portal.

• Bureau for Medical Services (BMS): Administers Medicaid policy and HCBS waivers (https://bms.wv.gov/).
• West Virginia Board of Physical Therapy (WVBOPT): Issues professional licenses and conducts audits (https://www.wvbopt.wv.gov/).
• WVMMIS Health PAS-Online: The official Medicaid provider enrollment and claims portal (https://www.wvmmis.com/).
• Mountain Health Trust: The state's managed care program overseeing services for enrolled members (https://bms.wv.gov/MHT/Pages/default.aspx).

3. Gatekeeping Prerequisites: Who Can Even Apply

Independent physical therapists and therapy groups must hold an active West Virginia license before initiating Medicaid enrollment. There is no Certificate of Need (CON) requirement for independent physical therapy practices in West Virginia, though Home Health Agencies employing PTs are subject to CON review by the West Virginia Health Care Authority.

Providers must also obtain a National Provider Identifier (NPI) and, if treating dual-eligible members, must be enrolled in Medicare. Therapists seeking to provide services under the Mountain Health Trust managed care program must secure network contracts with the individual Managed Care Organizations (MCOs) after completing state Medicaid enrollment.

• Professional Licensure: Active license from the West Virginia Board of Physical Therapy is a mandatory prerequisite.
• NPI Registration: Must possess a Type 1 (individual) or Type 2 (organization) National Provider Identifier.
• Medicare Enrollment: Required for providers intending to bill for members dually eligible for Medicare and Medicaid.
• MCO Contracting: Required for participation in the Mountain Health Trust managed care network; state enrollment alone does not guarantee MCO network admission.

4. Licensure and Certification Requirements

The West Virginia Board of Physical Therapy requires applicants to graduate from an accredited physical therapy program and pass the National Physical Therapy Examination (NPTE). Licenses are renewed biennially.

Licensees are subject to continuing education requirements and random audits. The board mandates 24 West Virginia board-approved continuing education (CE) hours per licensing period to maintain active status.

• Examination: Must pass the NPTE to assess basic entry-level competence.
• Continuing Education: 24 WV board-approved CE hours required per biennial licensing period.
• CE Audit: The board conducts a random 10% annual audit of licensees to verify CE compliance.
• Renewal Cycle: License and registration renewals occur on a biennial basis.

5. Medicaid Provider Enrollment

Physical therapists in private practice must enroll through the WVMMIS Health PAS-Online portal. The process requires submitting demographic information, licensure details, and banking information for electronic funds transfer.

Providers must complete the general enrollment requirements outlined in Chapter 300 of the BMS manual. Revalidation is required periodically to maintain active billing privileges.

• Enrollment Portal: Applications must be submitted electronically via WVMMIS Health PAS-Online.
• Required Documents: Current CV, medical license, malpractice face sheet, and board certifications.
• EFT Requirement: Providers must set up Electronic Funds Transfer for Medicaid reimbursements.
• Revalidation: Providers must revalidate their enrollment every 3 to 5 years as mandated by federal regulations.

6. Staffing, Training and Background Checks

Physical therapy services must be furnished by or under the direct supervision of a qualified physical therapist. When a Physical Therapy Assistant (PTA) provides the service, the supervising PT retains full clinical and billing responsibility.

All enrolled providers and their staff must undergo standard background screenings during the licensure and Medicaid enrollment processes to ensure they are not excluded from federal healthcare programs.

• Direct Supervision: PTAs must operate under the direct supervision of a licensed Physical Therapist.
• PTA Qualifications: Must hold an Associates of Arts degree and an active PTA license from the state board.
• Exclusion Checks: Providers must verify staff are not on the OIG LEIE or state Medicaid exclusion lists.
• Scope of Practice: Electromyography and certain electro-diagnostic studies have specific training and certification limits under W. Va. Code R. § 16-1-8.

7. Documentation, Policies and Records

Chapter 515 of the BMS manual dictates strict documentation standards for therapy services. Records must clearly substantiate the amounts charged to the Medicaid program and include the physician's prescription.

For school-aged children, documentation must clearly delineate between services provided by the school system (IEP) and private practitioners to prevent duplication of Medicaid billing.

• Physician Prescription: A written order from a licensed attending physician is required for all PT services.
• Treatment Plan: Must outline the diagnosis, prognosis, and specific intervention modalities.
• School Coordination: Parents must notify the local education agency in writing if opting for private PT instead of school-based Medicaid billing.
• Record Retention: Clinical and billing records must be made available upon request to BMS or its representatives.

8. Billing, Rates and Claims

Claims for physical therapy are submitted to WVMMIS using standard CPT codes for evaluations, re-evaluations, and specific modalities. Reimbursement rates are published on the BMS fee schedule.

Prior authorization is a critical billing gate. Services exceeding the 20-visit annual limit will be denied unless prior approval is obtained from the state's utilization management contractor.

• Visit Limit: 20 visits per calendar year are allowed without prior authorization.
• Prior Authorization (PA): Required for any visits beyond the 20-visit threshold.
• UM Contractor: PA requests are submitted to the state's medical review contractor (historically WVMI/Kepro, now Acentra Health).
• MCO Billing: If a member is in an HMO, services must be prior authorized and billed according to that specific MCO's rules.

9. Approval Sequence and Timeline

The approval sequence begins with obtaining a state license, which requires passing the NPTE and submitting transcripts. Once licensed, the provider applies for an NPI and Medicare enrollment if applicable.

Medicaid enrollment through WVMMIS typically takes 30 to 90 days, depending on application completeness and background screening times. MCO credentialing adds an additional 60 to 120 days post-Medicaid enrollment.

• Licensure: 4-8 weeks after exam passage and application submission to WVBOPT.
• Medicaid Enrollment: 30-90 days via the WVMMIS portal.
• MCO Credentialing: 60-120 days after state Medicaid approval.
• PA Turnaround: Prior authorization requests for extended visits typically take 7-14 days for review.

10. Common Denials and Survey Findings

Claims are frequently denied for exceeding the 20-visit annual limit without an approved prior authorization on file. Providers must track visits carefully, as the limit applies per member, per calendar year, regardless of the provider.

Another common denial reason is duplication of services for pediatric members receiving therapy in the school system. BMS strictly prohibits paying private practitioners for the same services billed by a county board of education.

• Limit Exceeded: Billing for visit 21+ without a PA from the UM contractor.
• Duplication of Service: Concurrent billing by a private PT and a school district for the same member.
• Missing Prescription: Failure to maintain a valid, signed physician order in the clinical record.
• Lapsed License: Billing during a period where the PT or PTA failed to complete the 24 CE hours and renew their license.

11. Key Contacts and Resources

Providers should utilize the official state portals for the most current manuals, fee schedules, and enrollment forms. The Bureau for Medical Services publishes Chapter 515 and all relevant policy updates.

For licensure questions, the West Virginia Board of Physical Therapy is the primary contact. For claims and enrollment technical support, providers must contact the WVMMIS helpdesk.

• Bureau for Medical Services (BMS): Policy manuals and fee schedules (https://bms.wv.gov/).
• WV Board of Physical Therapy: Licensure and CE requirements (https://www.wvbopt.wv.gov/).
• WVMMIS Provider Portal: Enrollment and claims submission (https://www.wvmmis.com/).
• Mountain Health Trust: Managed care program information (https://bms.wv.gov/MHT/Pages/default.aspx).

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