Pursuant to Section 1128 and Section 1902(a)(39) of the Social Security Act, the West Virginia Medicaid Program will not reimburse a provider for any services or items that were rendered or ordered/prescribed by a sanctioned (e.g., suspended, excluded) provider. The effect of the provider's sanction precludes them from furnishing, ordering, or prescribing services or items to a Medicaid member. Claims for services/items rendered/ordered/prescribed by a sanctioned provider with dates of service or dispensing after the effective date of the sanction, will be rejected or disallowed if discovered during a post-payment review.
In accordance with the Patient Protection and Affordable Care Act (Pub. L. 111-148, enacted on March 23, 2010, as revised by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), enacted on March 30, 2010, together known as the Affordable Care Act (ACA), the West Virginia Medicaid Program is required to terminate enrollment of any provider that is excluded under Medicare or any other state Medicaid Agency. Excluded individuals and entities prohibited from participating in the West Virginia Medicaid Program are identified in the following list. Excluded individuals and entities are listed according to the type of provider they were at the time of exclusion; however, they are excluded from participating in providing services in the Medicaid program in all categories of services and in any capacity. The exclusion remains in effect until they are removed from this list.
Any provider participating or applying to participate in the West Virginia Medicaid program must search this list and the Federal Office of Inspector General's List of Excluded Individuals and Entities (LEIE) at http://oig.hhs.gov/fraud/exclusions.asp
on an annual basis to determine if any existing employee, contractor, owner or board member has been excluded from participation in the Medicaid program. Also, any provider participating or applying to participate in the West Virginia Medicaid program must search both lists prior to hiring staff to ensure that any potential employees, contractors, owners or board members have not been excluded from participating in the Medicaid program.
Document link provided below:
June 2012 Excluded Providers - Previously Enrolled with WV Medicaid
June 2012 Excluded Providers - Non-Enrolled with WV Medicaid
Revised License Maintenance Policy
Health care providers, who, under the State Plan and/or State statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with West Virginia Bureau for Medical Services (BMS) Provider Enrollment Unit, Molina. A provider's participation in the WV Medicaid Program may be terminated if Molina cannot verify the current status of a provider's license.
Document link provided below:
License Lapse Policy