West Virginia Authorization Forms

Click here to confirm member specific eligibility and benefits: this requires log-in (located in upper right corner)
If you do not have an account, you can create one by clicking on First-Time user.

Click here to determine when a prior authorization request is required, as well as any pre-service requirements or required documentation. 

Click here to review Clinical Review Criteria used to evaluate prior authorization requests. 

Below are the available forms that can be used: 

ABA Assessment & Treatment Plan Forms

• ABA Assessment Requests - electronic submission (commercial ABA providers only)
• ABA Treatment Plan - electronic submissions

Psychological Testing Request Forms

• Optum Psych Testing Request Form - electronic submission
  
• Medica Psych Testing Request Form

Transcranial Magnetic Stimulation (TMS)

• TMS Prior Authorization Request Process Training
  • Provider Express - Login Training
  • Prior Authorization Request
  • Please Login and proceed to Auth Inquiry

All other Non-Routine Services - West Virginia Electronic Submission Form - commercial providers only

• West Virginia Prior Authorization - electronic submission