These medical polices apply to our West Virginia Marketplace plans.
Medical policies offer guidance on determination of medical necessity and appropriateness of care for approved benefits. Benefit determinations and coverage decisions are subject to all the terms and conditions of CareSource including eligibility, definitions, specific inclusions or exclusions, and applicable state or federal laws.
The medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. CareSource is not responsible for, does not provide, and does not represent itself as a provider of medical care.
Policies are considered guidelines and are not intended to infer benefits or coverage for a specific member. Benefit determinations are based on the specific facts of each member’s case. If a service or supply is not eligible for coverage, a member and the treating provider may proceed with that service or supply after receiving a denial from CareSource for the requested non-covered service.
Existing clinical policies are regularly reviewed and updated. New policies are added as appropriate, while previous versions are maintained in the policy archive. These policy changes are maintained on this site.
The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.