1. Program Definition and Services
Case Management Services (including Waiver Care Coordination) under West Virginia’s Medicaid waivers deliver comprehensive planning, advocacy, and service oversight. Case managers act as the primary locus of coordination, ensuring that individuals enrolled in Home and Community-Based Services (HCBS) programs live in the least restrictive environment possible. Core professional services include:
- Functional Assessment
- Care Plan Design (PCSP)
- Service Interconnection
- Quality Monitoring
2. Regulations
- West Virginia Bureau for Medical Services (BMS) Medicaid Manual: Chapter 500 (Waiver Services)
- The CMS HCBS Settings Final Rule (42 CFR 441.301)
- Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules
3. Licensing or Certification
An agency must secure formal credentialing as an approved Waiver Case Management Agency through BMS. To adhere to federal conflict-of-interest mandates, agencies must maintain strict operational walls, which typically prevent an organization from delivering both Case Management and direct hands-on care (like personal care or residential supports) to the same individual.
4. Responsible State Agencies
- West Virginia Department of Human Services (DoHS): Exercises top-level administrative authority over state waiver and public assistance networks
- Bureau for Medical Services (BMS): Manages Medicaid enrollment, provider compliance, and billing frameworks
- Acentra Health: Acts as the utilization management contractor evaluating clinical eligibility, conducting level-of-care determinations, and approving PCSP
5. Application Process
- Register your business legal entity with the West Virginia Secretary of State
- Obtain a Federal EIN and a Type 2 National Provider Identifier (NPI) matching case management taxonomies
- Apply for formal Case Management provider status through BMS/DoHS
- Pass comprehensive staff fingerprinting and criminal background checks via WV CARES
- Complete electronic billing enrollment through the Gainwell Technologies MMIS portal
6. Required Documentation
- Business entity registration and Type 2 NPI documentation
- Proof of commercial liability insurance, errors and omissions coverage, and employee fidelity bonding
- Case Management Policy Manual detailing conflict-of-interest mitigation, PCSP design rules, documentation timelines, freedom-of-choice protection, and quality assurance workflows
- Verified WV CARES background check records and human services bachelor's degree verifications for all case managers
- Standardized intake assessment tools, monthly/quarterly tracking logs, and crisis-intervention templates
7. Timeline for Approval
The combined track for corporate setup, operational policy validation, WV CARES clearance, and Gainwell portal activation typically takes 2 to 3 months.
8. Pre-Application Process
Incorporate your entity in West Virginia, secure an EIN and Type 2 NPI, obtain required liability and fidelity insurance lines, and design your conflict-of-interest protection protocols.
9. Pre-Application Training
Agency administrators and care coordinators must complete mandatory state training modules. These focus on utilizing the Acentra Health portal, person-centered planning frameworks, and waiver documentation compliance.
10. Additional Notes
- Case management units are tracked and billed using fractional or rounded intervals (specific unit increments for Healthcare Common Procedure Coding System code T1017) as regulated by BMS
- Agencies must continuously offer participants a totally uncoerced choice of service providers, ensuring clear separation between care planning and direct service execution
Why Choose Waiver Consulting Group?
Starting or expanding your Medicaid waiver-funded agency can feel overwhelming, but it doesn't have to be. At Waiver Consulting Group, we simplify the process by guiding you through licensing, compliance, provider enrollment, policies
With proven expertise, a structured process, and ongoing support
To get started, click the link to request portal access