Authorization Guidelines

Coupled with applicable federal and state rules, regulations, clinical coverage policies, and other guidance, Vaya Health uses the authorization guidelines in making decisions about requests for authorization. You and your staff must be familiar with them as they apply to the conditions and diagnoses you treat. For services that require authorization, you may not seek payment for amounts or units that exceed those approved for authorization by Vaya.

Authorization Guidelines 

Acute Services Authorization Guidelines

• Medicaid 1915(b) and Non-Medicaid Authorization Guidelines for Acute Services (04/18/23)

Medicaid 1915(b) and (b)(3) Services Authorization Guidelines

• Medicaid 1915(b) Authorization Guidelines for Mental Health/Substance Use Services – Adult (04/18/23)
• Medicaid 1915(b) Authorization Guidelines for Mental Health/Substance Use Services – Child (03/19/24)
• Medicaid 1915(b)(3) Authorization Guidelines for Mental Health/Substance Use Services (03/01/24)
• Medicaid 1915(b) and (b)(3) Authorization Guidelines for Intellectual/ Developmental Disabilities Services (04/18/23)
• Medicaid 1915(b) Research-Based Behavioral Health Treatment Services for Autism Spectrum Disorder (10/05/23)

Medicaid 1915(i) Services Authorization Guidelines

• Medicaid 1915(i) Service Authorization Guidelines (02/19/24)

Medicaid ‘In Lieu of’ Services Authorization Guidelines

• Medicaid Authorization Guidelines for ‘In-Lieu of’ Services (03/19/24))

Medicaid 1915(c) Services Authorization Guidelines

• Medicaid 1915(c) Authorization Guidelines for Innovations Services (04/18/23)

Non-Medicaid Services Authorization Guidelines

• Non-Medicaid Authorization Guidelines for Mental Health/Substance Use Services – Adult (03/19/24)
• Non-Medicaid Authorization Guidelines for Mental Health/Substance Use Services – Child (04/18/23)
• Non-Medicaid Authorization Guidelines for Intellectual/Developmental Disabilities and Traumatic Brain Injury Services (07/14/23)

Vaya Total Care Physical Health Services Authorization Guideline

• Physical Health Services: Codes Requiring Prior Authorization (please note that except for Personal Care Services, prior authorization is not required for physical health services until dates of service beginning Feb. 1, 2025)
• Vaya follows current posted NC Medicaid clinical coverage policies, available on the Program Specific Clinical Coverage Policies page of the NC Department of Health and Human Services website.
• Imaging Services: Note that Vaya Total Care Medicaid Clinical Coverage Policy 1K-7 Prior Approval for Imaging Services also applies.
• Physician Administered Drug Program Catalog