Dental Services
Medicaid members under 21 years of age are eligible
for covered diagnosc, prevenve, restorave, periodoncs,
prosthodoncs, maxillofacial prosthecs, oral
and maxillofacial surgery, and orthodoncs.
Dental periodic screenings are based on the
recommended guidelines set forth by the
American Academy of Pediatric Denstry (AAPD)
and Bright Futures. Covered dental services for
enrolled adults 21 years of age and older are
divided into two levels of service: 1) emergent
procedures to treat fractures, reduce pain, or
eliminate infecon and 2) diagnosc, preventave,
and restorave services. Prior authorizaon may be
required for specic emergent services and when
service limits are exceeded
Beginning January 1, 2021, services classied as
diagnosc, preventave, and restorave in nature
will require authorizaon prior to services being
rendered and have a coverage limit of $1,000 per
member per calendar year. Members are
responsible for payment of service cost exceeding
the $1,000 yearly limit. Remaining balances at the
end of the year CANNOT be carried over to the
following year. Services classied as cosmec in
nature are not covered for adults over the age of
21.
Out-of-State Medicaid Coverage
You must receive your Medicaid services from a
West Virginia provider except in the following
circumstances:
• Some medical providers praccing within 30
miles of the West Virginia border have been
granted “border status”. These medical
providers are considered in-state providers and
do not have to obtain prior approval for
services except in those instances where it is
required of in-state providers;
• Emergency treatment that is received while
traveling or visiting out of state; or
• Treatment received after prior approval from
Medicaid.
Out-of-state services are usually not approved if
they are available in West Virginia.
Denial of Payment for Services
There are certain reasons why Medicaid may deny
payment of your medical bills or prescription drugs:
• Your doctor may not have asked for special
permission (prior approval) for certain services
paid;
• Certain services are not covered by the West
Virginia Medicaid Program;
• You may have gone beyond the limits of
coverage;
• You may not have been entitled to a Medicaid
card on the date of services; or
• Your doctor may not have filled out the forms
properly or may not have been a Medicaid
provider when the service was rendered.
Non-Emergency
Medical Transportation
Non-Emergency Medical Transportaon (NEMT) is
available to Medicaid members who need
assistance in order to keep scheduled medical
appointments and treatments.
In order to be eligible for NEMT, a person must be a
Medicaid member and have an appointment for
medical treatment that is approved under Medicaid
guidelines.
Eecve September 1, 2018, for more informaon,
to request gas mileage reimbursement, or schedule
a trip, please call the Medicaid NEMT broker at 1-
844-549-8353, Monday-Friday from 7 a.m. to 6 p.m.
at least ve business days before your
appointment.
You will need to have the member’s name,
Medicaid ID number, home address, phone
number, where the member is to be picked up, the
name, phone number, and address of the health
care provider, the date and me of your
appointment, and general reason for the
appointment. Also, please let the operator know if
you have any special needs such as a wheelchair
accessible vehicle, assistance during the trip, or
someone to ride with you.
10 Effective April 1, 2022