Requesting authorization for services, supporting the request with required documentation and demonstrating medical necessity is the responsibility of the provider who will be delivering the service. All providers must use the electronic AlphaMCS Service Authorization Request (SAR) to request prior authorization.
If you experience difficulty submitting online, download a copy of the Service Authorization Request (Paper SAR) form. Please complete, scan and send the form via electronic mail or e-fax to UM@vayahealth.com.
For help with questions regarding SARs, contact Vaya Health Utilization Management (UM) staff at 1-800-893-6246, ext. 1513.
A SAR must be submitted for each service requiring authorization. Please note:
- All SARs must be submitted electronically via AlphaMCS. In documented instances where electronic transmittal is not possible, Vaya may accept transmittal via facsimile, U.S. mail or hand delivery. It is your responsibility to maintain documentation evidencing the date the request was submitted.
- For assistance using AlphaMCS, visit our AlphaMCS page.
- Except for requests based on retrospective Medicaid eligibility, all SARs must have a service start date that is on or after the date of SAR submission.
- Providers must include the name of the individual who is providing the service or who is most knowledgeable about the case, along with that person’s telephone number, at the end of the Justification for Service Request field in AlphaMCS.
For initial requests, SARs must be submitted at least 14 days (but no more than 30 days) prior to the requested start date of services, except for inpatient or other expedited requests. Additionally:
- For routine services, requests to renew an existing authorization must be submitted at least 14 days prior to the end of the previous authorization in order to avoid a gap in authorization or payment. It is your responsibility to submit a SAR for each subsequent service authorization request prior to the expiration of the current authorization and to conduct a clinical review of the member’s ongoing need for services.
- All network providers are required to submit initial and continuing requests at least 14 days before the requested start date or end of prior authorization, except for crisis or inpatient requests and requests that meet criteria for expedited review.
- If continued authorization is requested for inpatient and facility-based crisis services, the request and supporting documentation must be submitted to Vaya 24 hours prior to the lapse of the current authorization, unless the renewal date falls on a weekend or official Vaya holiday, when the request may be submitted the next business day for retrospective review.
Please note: If you believe that taking the time for a standard review could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function, you may request expedited processing of the request. Clinical justification of the risk of harm should be submitted with the request.
All authorization requests (prospective, concurrent and retrospective) are to be submitted electronically via AlphaMCS. If your organization does not have access to the AlphaMCS portal, you may submit a cover letter, a print screen from NCTracks that shows the Medicaid eligibility determination date and only the necessary information from the medical record to fully justify the request to Vaya. Requests must be submitted within 90 days of the eligibility determination to the following address:
Vaya Health
Attn: Retrospective Reviews
200 Ridgefield Court, Suite 206
Asheville, NC 28806
Inpatient psychiatric units
Providers submitting authorization requests/SARs for members admitted to an inpatient psychiatric unit must complete and include the following document/s with the request:
Initial authorization: Regional Assessment and Referral Form (RARF)
Continued authorization: Inpatient Concurrent Review Form
ADATC
Providers referring Vaya members to an Alcohol and Drug Abuse Treatment Center (ADATC) for detox services should fax a Regional Referral Form to 828-257-6268. Providers referring Vaya members to an ADATC for rehabilitation services should fax the Regional Referral Form and clinical assessment to 828-257-6231.
Broughton State Hospital
Providers who refer Vaya members to Broughton State Hospital must complete the Regional Referral Form and fax the form and assessment to Vaya Member Services at 1-877-917-9887 to begin the process. Providers should follow the same process for members referred to Broughton who are diagnosed with (or with a suspected diagnosis of) an intellectual and/or developmental disability (IDD) and a co-occurring mental health disorder.
Child and adolescent residential placement
The Universal Child and Adolescent Residential Placement Application is designed to help referring agencies or individuals streamline discharge planning and eliminate the time and redundancy associated with multiple agency-specific applications. Use of this form does not, and should not be construed to, guarantee authorization of residential or other treatment by Vaya. Responsibility for appropriate discharge from inpatient facilities remains with the discharging provider