Vaya Health network providers, their billing agents, and clearinghouses must submit all claims via the Vaya Provider Portal or through a HIPAA-compliant Electronic Data Interchange (EDI) file, unless your contract specifically states an alternative method. Vaya does not accept paper claims from network providers. Vaya accepts only HIPAA-compliant transactions as required by law:
- When billing through Vaya’s secure Provider Portal, use the CMS-1500 or UB-04 webforms (as appropriate to the service).
- When billing through Vaya’s secure file transfer protocol (SFTP) web portal, use HIPAA-compliant 837I (Institutional) or 837P (Professional) EDI files.
Please note we accept only .txt and x12 file formats. We do not accept .pdf or .xlsx files.
For more information, refer to Vaya’s Provider Operations Manual.
All network and out-of-network providers must submit all claims electronically unless otherwise permitted by the provider’s contract with Vaya (or one of our subcontractors) or the Vaya Provider Operations Manual.
For help, use our online Provider Service Desk Form or contact your assigned Claims Specialist. You may also call our Claims Department at 1-800-893-6246, ext. 2455 (behavioral health, intellectual/developmental disability, and traumatic brain injury services), or ext. 2456 (physical health services).
To pay any provider, regardless of network status, Vaya must have the provider’s W-9 form on file. Vaya accepts paper claims from out-of-network providers in the following circumstances:
- Claims for emergency and post-stabilization services
- Claims for continuity of care periods as defined by the North Carolina Department of Health and Human Services (only if the provider does not have a member-specific out-of-network agreement with Vaya)
Out-of-network providers filing paper claims must submit an accurate CMS-1500 or UB-04 billing form containing the correct data elements. Vaya will not accept copies of these forms or handwritten forms.
Providers may deliver these materials in person or mail them to Vaya Health, Attn: Claims, 200 Ridgefield Court, Suite 218, Asheville, NC 28806.
Network providers who wish to submit via a clearinghouse using an 837 file must complete training, successfully submit and receive test files, and execute a trading partner agreement.
Detailed instructions for 837 file submission are provided in the HIPAA Transaction Professional (837P) and Institutional (837I) Transaction Companion Guides. HIPAA-compliant ANSI transactions are standardized; however, each payor can exercise certain options and require use of specific processes.
Vaya returns the following HIPAA transaction files to providers: 999 (an acknowledgment receipt), 824 (a line-by-line acceptance/rejection response), and 835 (an electronic version of the remittance advice [RA]). These files are returned to the submitter’s SFTP In/Out folder within 30 minutes of file upload.
Pharmacy providers are required to submit all claims electronically using up-to-date National Council for Prescription Drug Programs standards. Pharmacies should use the following billing information to transmit claims:
- RxBIN: 610241
- RxPCN: RXVAYA
- RxGroup: Member-specific (see Medicaid ID card for details)
- Member ID: Member-specific (see Medicaid ID card for details)
Claims submission timeframes
Claims for Medicaid services must be filed by the provider and received by Vaya within 365 days of the date of service or the date of discharge. Claims for State-funded services must be filed and received within 90 days. All initial claims submitted past these deadlines will be denied (unless there is an applicable exception, for example, retroactive Medicaid eligibility) and cannot be resubmitted. Claims in which Vaya is the secondary payor must be submitted within 180 days of the date you receive a denial from a first- or third-party payor.
We encourage network providers to submit routine billings on a weekly or bi-weekly schedule in conjunction with our checkwrite schedule.
Claims submission resources
- 5010 Clarification Manual for Medicaid – Professional
- 5010 Clarification Manual for Medicaid – Institutional
- 5010 Clarification Manual for Non-Medicaid – Institutional
- 5010 Clarification Manual for Non-Medicaid – Professional
- Steps for 837p and 837i Testing and Approval
- EDI Enrollment Form
- EDI 270 and 271 Companion Guide
- EDI 276 and 277 Companion Guide
- EDI Real-Time 270 and 271 Companion Guide
- EDI Real-Time 276 and 277 Companion Guide
- Vaya Health-Tested Clearinghouses
- Medicaid Covered Diagnoses
- Medicaid Covered Diagnoses: Special Needs Populations
- NCTracks
- High Volume Claim Inquiry Form