Who established the criteria?

The West Virginia Bureau for Medical Services and its Drug Utilization Review Board. This board consists of eighteen currently practicing health care professionals. The demographics of the boards are nine physicians, eight pharmacists, and one nurse practitioner. The WVBMS is represented by the Medical Director, the Commissioner of Health and Human Services, the Pharmacy Unit Coordinator and DUR Coordinator.

Meetings are held quarterly on the last Wednesday of the 2nd, 5th, 8th and 11th month. These are held in the conference room at the WVBMS's main office in Charleston, WV.

What is the Prior Authorization drug utilization process?

The following steps show the process of identifying drug utilization review issues:

1. WVBMS and its DUR Board review the High Cost, High Use, and High-Risk medications being utilized within the WVBMS system.
2. They then identify a medication or a classification of medications that are possibly over-utilized or inappropriately being used.
3. The DUR Board then asks for the development of criteria of use for that particular area of drug utilization for which they are concerned.
4. Criteria are researched from current accepted journals, publications, and in conjunction with the pharmaceutical industry.
5. The researched criteria are presented before DUR Board in a public meeting. The public meetings have open discussion periods at the end of each meeting.
6. Criteria are then usually sent to selected practicing professionals in the area of review for input and are placed on the WVBMS Website for Public Comment.
7. At the next DUR Board meeting assessments are collected and reviewed and criteria are approved, denied or modified.
8. An implementation date is established through the billing computer contractor.
9. Professional education is then performed.
10. Prior authorization process is initiated on the declared date.

What happens in the Prior Authorization process?

The following steps show the process of Prior Authorization:

1. Prescription is written by practitioner.
2. Prescription is communicated to pharmacy provider.
3. The prescription order is reviewed by the pharmacy provider.
4. The prescription order is entered into the on-line claims processing computer.
5. The on-line computer approves or rejects claim as per computerized program criteria.
6. If claim is denied by computer an electronic message states, the prior approval must be obtained through the RDTP.
7. If the rejected claim is approved by RDTP, the Medicaid processing computer will be modified by RDTP to allow payment for the claim.
8. If the claim is denied and the physician cannot be reached, a 72-hour supply may be dispensed by the pharmacy at no risk to the pharmacy.
9. The pharmacy provider can then take three possible courses of action:
1. Contact the physician to get the order changed or clarified and then recall the RDTP for approval.
2. Contact the physician's office and have them recall the RDTP.
3. Give the prescription back to the patient and let them go back to the physician.
10. The RDTP will automatically notify the physician of any pending or denied claims by faxed letter.

Is there a medical appeal process?

If a PHYSICIAN feels that the criteria does not meet this individual patient's needs, they always have a right of appeal the RDTP decision to the medical director of the WVBMS. Appeals can be made by the physician faxing a written appeal request to WVBMS Medical Director. Appeal Fax Number 800-531-7787.​