Prior to submitting claims for reimbursement, providers must ensure the individual is eligible for and enrolled in a health plan managed by Vaya Health.
Mobile crisis and detoxification services are available to anyone within the Vaya region, regardless of eligibility for Medicaid or State-funded services. However, the individual must be enrolled with Vaya for provider reimbursement.
Eligibility for Medicaid services
In North Carolina, local Departments of Social Services determine Medicaid eligibility. NC Medicaid sends eligibility information to Vaya daily. This information is available in the Vaya Provider Portal.
Eligibility for State-funded services
Eligibility information for State-funded services recipients is available in the Provider Portal. To be eligible for State-funded behavioral health, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) services, the individual must reside in the Vaya region and be a U.S. citizen or legal resident. The only exception is for emergency services as defined in 42 CFR § 438.114.
Network providers must interview individuals seeking State-funded services and document additional criteria listed below.
Mental health and substance use disorder services:
- Household income for the individual must be 300% or less of the most recent federal poverty guidelines, based on family size.
- The individual must be uninsured, seeking a service not covered by their insurance plan (and an alternative clinically appropriate service is not available), or the cost-sharing associated with the service is unaffordable (as determined by Vaya).
I/DD and TBI services:
- There is no minimum financial eligibility for I/DD or TBI services.
- The individual must be uninsured, seeking a service not covered by their insurance plan (and an alternative clinically appropriate service is not available), or the cost-sharing associated with the service is unaffordable (as determined by Vaya).
- The individual must have applied for Medicaid.
Some Vaya members with Medicaid may also qualify for State-funded services if an equivalent Medicaid service is not available.
Enrollment in State-funded services
Providers delivering State-funded services to Vaya recipients are required to keep recipient eligibility information current and submit updates if the individual’s circumstances change. Network providers are responsible for investigating the person’s ability to pay prior to requesting State-funded services from Vaya and must determine the following:
- If an individual presenting for services meets financial eligibility requirements for Medicaid (if so, you must offer to help them apply for Medicaid)
- If the individual has Medicare or any other third-party insurance coverage, including insurance through a non-custodial parent, an employer, or the Health Insurance Marketplace (individuals with third-party coverage may enroll with Vaya as the secondary payor)
Eligibility and enrollment assistance
Contact our Eligibility and Enrollment Team at 1-800-893-6246, ext. 2355, or EandE@vayahealth.com. We can help with:
- Looking up a member/recipient in the Provider Portal
- Enrolling a recipient in State-funded services
- Updating member/recipient information
- Answering questions about Client Update Requests
- Verifying a member’s Medicaid category of eligibility
- Obtaining an individual’s Common Name Data Service (CNDS) number
- Answering questions about a member’s Medicaid eligibility
- Answering questions about a recipient’s rider/target population
- Understanding member/recipient demographic and eligibility information in NCTracks versus the Provider Portal
- Verifying third-party insurance and dual eligibility
- Answering questions about discharges for State-funded services recipients
- Verifying Medicaid, State, and coordination of benefits coverage for providers and other Vaya departments