What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. West Virginia-only details below.
Confirm plan type: West Virginia: Start Here.
West Virginia PA rules
West Virginia's core PA statute is W. Va. Code § 33-24-7s (SB 267, effective January 1, 2024). Parallel requirements apply to HMOs under § 33-25A-8s. SB 833 (2025) extended episode-of-care PA rules across PEIA, Medicaid, and commercial carriers.
Electronic portal & response deadlines (§ 33-24-7s)
- PA must be submitted through an electronic portal (URL on the insurance card); one PA per episode of care
- Standard PA: decision within 5 business days after complete electronic submission
- Urgent PA: decision within 2 business days when delay would seriously jeopardize life, health, or safety
- Incomplete submissions: insurer identifies deficiencies within 2 business days; provider has 3 business days to supplement; insurer decides within 2 business days after receipt
- Quarterly updated, science-based list of services requiring PA on the carrier website
Gold carding (§ 33-24-7s(k))
Providers averaging 30 procedures per year with a 90% final prior approval rate over a six-month period may be exempt from PA for at least 6 months (renewable). Excludes experimental treatment, non-covered benefits, out-of-network services, and—after SB 833—pharmaceutical medications. FQHC behavioral health may be exempt under pending/clarifying legislation.
Other protections
- 90-day cross-plan portability: approved PA honored by other WV insurers and PEIA for three months
- Discharge medications: at least 3 days of inpatient discharge Rx without new PA (subject to cost limits in statute)
- PA peer-to-peer appeal: within 5 business days of request; full PA appeal decision within 10 business days
- OIC may assess civil penalties for violations (§ 33-3-11)
OIC guidance: Insurance Bulletin 24-03 on SB 267 compliance.
Where to look up PA rules
Check your plan materials and the carrier's PA portal (required on the insurance card). Carriers must post a comprehensive PA list updated at least quarterly.
Carrier links: West Virginia prior auth & internal appeals links.
Medicaid
West Virginia Medicaid and Mountain Health Promise use separate utilization management under BMS and MCO contracts—not commercial § 33-24-7s deadlines for most member benefit disputes.
If PA is denied
Request a peer-to-peer review with the carrier, then appeal through internal grievance and OIC external review if needed.
Urgent care
Emergency care cannot require prior authorization. For urgent PA, West Virginia requires a decision within 2 business days when the clinical situation meets statutory urgency criteria. For urgent medical necessity disputes after a denial, request expedited internal grievance and may qualify for 72-hour expedited external review (CSR 114-97-7).