Claims

Vaya offers 3 ways for providers, or their authorized third-party clearinghouse, to submit claims: 

• Through the secure Provider Portal 
• Through a secure file transfer protocol (SFTP) site as x12 standard HIPAA-compliance 837I institutional or 837P professional 
• Through electronic data interchange (EDI) files and via paper submission (in limited and prescribed circumstances only) 

All network and out-of-network providers must submit all claims electronically unless otherwise permitted by a provider’s contract with Vaya or one of its subcontractors or the Provider Operations Manual. Vaya only accepts paper claims from out-of-network providers in the following circumstances: 

• For emergency services 
• Existing and active prior authorizations on file with NC Medicaid Direct, LME/MCOs, or Standard Plans for the first 90 days after Tailored Plan implementation to ensure continuity of care 
• For the first 60 days after Tailored Plan launch, for Medicaid-eligible nonparticipating/out-of- network providers equal to that of network providers until the end of the episode of care or the first 60 days after Tailored Plan launch, whichever is less 
• In other limited circumstances with written approval from Vaya Paper claims are only accepted via mail or hand delivery. 

All medical claims must be billed on a CMS-1500 billing form, except for inpatient, hospital emergency department (ED), ICF/MR, therapeutic leave services, and other services, which must be billed on a UB- 04 form. 

Claims for services must be filed by the provider and received by Vaya within 180 days of the date of service or, for inpatient claims and nursing facility claims only, the date of discharge. All initial claims submitted past the 180-day deadline will be denied (unless there is an applicable exception, for example retroactive Medicaid eligibility) and cannot be resubmitted. 

Vaya only accepts claims from out-of-network providers if the provider delivered emergency or post- stabilization care services to a Vaya member in accordance with federal law or if the provider has an out-of-network agreement for other services with Vaya. 

Claims Payments 

Within 18 calendar days after Vaya receives a “clean claim” or invoice from a provider for a medical claim, Vaya will approve or deny payment. A clean claim is a claim for a covered service that meets all the following criteria: 

• Can be processed without obtaining additional information from the provider or from a third party 
• Is timely received by Vaya 
• Is on a completed, legible CMS 1500 form or UB 04 form, or electronic equivalent 
• Is true, complete, and accurate, and is not a claim from a provider who is under investigation for fraud or abuse, a claim under review for medical necessity, a claim subject to coordination of benefits, or a claim that cannot be successfully processed through the NCDHHS MCIS as an encounter 

Vaya pays approved medical claims within 30 calendar days after the date of approval. The 30-day period includes the first 18 days to determine if a claim can be paid or denied. 

All payments to network providers are processed through electronic funds transfer (EFT) according to the checkwrite schedule posted on the Vaya website. If any approved claim is not paid within the required time period, Vaya must pay the provider interest, which is accrued at the annual rate of 18% of the claim amount beginning on the date following the day on which the payment should have been made. The total accrued interest amount is remitted to the provider in the calendar month following the payment of the claim. 

For more information about claims submission and adjudication, please refer to the Provider Operations Manual. 

Pharmacy Claims 

Pharmacy providers are required to submit all claims electronically using up-to-date NCPDP standards. Pharmacies should use the following billing information to transmit claims: 

• RxBIN: 610241 
• RxPCN: RXVAYA 
• RxGroup: Member Specific – See ID card for details 
• Member ID: Member Specific – See ID card for details 

Within 14 calendar days after Vaya receives a clean claim or invoice from a provider for a pharmacy claim, Vaya will either approve or deny payment or determine that additional information is required to approve or deny the claim. Vaya pays approved pharmacy claims within 14 calendar days after the date of approval. The 14-day period includes the 14 days to determine if a claim can be paid or denied.