Vaya Health’s Utilization Management (UM) Department reviews service authorization requests and provides clinical oversight of the services covered in our benefit plans. Authorization decisions are based on medical necessity. When reviewing medical necessity, UM staff consider member needs, Medicaid Waiver and clinical coverage policy requirements, federal regulations, clinical practice guidelines (if applicable), EPSDT requirements (for Medicaid beneficiaries under age 21) and the availability of funding for non-Medicaid and Medicaid (b)(3) services. Vaya does not offer any type of incentive for UM staff to deny, limit or discontinue medically necessary services to any member.
Not all services require prior authorization. For more information, please refer to our SAR Process and Authorization Guidelines pages. If a Vaya UM clinician is unable to authorize a requested service, it is referred to Peer Review.
All UM decisions and coverage of service decisions are consistent with Vaya’s Clinical Practice Guidelines, Leveling Tools and HEDIS Measures (approved 09/11/2019). Clinical practice guidelines are designed to guide providers on how to follow national and community standards of practice. Clinical practice guidelines are not a substitute for the advice of a healthcare professional or the UM reviewer or peer reviewer making medical necessity determinations.
Vaya adopts guidelines that are based on valid and reliable clinical evidence (evidence-based practices) or a consensus of licensed professionals. We also may adopt clinical practice guidelines promulgated by nationally recognized peer review organizations such as the American Psychiatric Association (APA), the American Academy of Child Psychiatrists (AACAP), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Veterans Administration (VA), the Center for Child and Family Health, the British National Institute for Health and Clinical Excellence, the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Mental Health (NIMH) and the National Center on Birth Defects and Developmental Disabilities.
Network providers are required to maintain or advance the quality of services through the demonstration of practice consistent with Vaya’s adopted Clinical Practice Guidelines.