Member Responsibilities

The responsibilities of Medicaid members include, but are not limited to, the following:

• Notifying providers in a timely manner if unable to keep an appointment.
• Notifying providers promptly of changes in Medicaid coverage.
• Notifying providers of any changes in other insurance coverage, such as Medicare or private health insurance.
• Presenting a valid Medicaid identification card at each visit.
• Forwarding money or denials received from other insurance payers to their Medicaid providers.
• Informing their local WV DHHR office of any changes in address, income, etc.
• Paying providers required co-pays, if applicable.

Member Liability

• Payments denied for provider error. For example:
• Claims filed more than one year after date of services
• Wrongful billing or missing information
• Billings denied because the provider did not:
• Follow procedures
• Obtain prior approval from Medicaid or the managed care provider, if applicable.
• Notify the member before the service is provided that is not covered by Medicaid.
• Charges remaining after payments by insurance or Medicaid are made.
• Fees for missed appointments

Member Responsibilities for Certain Changes

Prior to services being rendered by a provider, the provider must inform or give notice to the member that the provider will not bill Medicaid for the services and the member will be responsible for the charges. Medicaid members, if given prior notice, may be billed for:

• Services received after Medicaid benefits are exhausted
• Services not medically necessary that the member elected to receive
• Services not covered by Medicaid that the member elected to receive
• Non-emergent services not prior-approved, if applicable
• Convenience items not required for medical care
• Services rendered when the member is not eligible
• Services provided when the member refuses to use other available insurance. The exception to this is the non-methadone medication assisted treatment.