Claims Adjudication and Payments

RAs and Claims Inquiries 

The remittance advice (RA) and electronic 835 (for claims submitted using EDI files) are standard methods of communicating back to providers how each claim has been adjudicated. RAs are available in the download option of the Provider Portal following each checkwrite. RAs report whether claims are approved, denied, or recouped and the reason code for each adjudication. 

Vaya does not make advance payments or payments outside the posted checkwrite schedule, except in documented situations in which a provider was not paid due to an error of Vaya or its vendors. We must comply with liens imposed by courts or government agencies such as the IRS or NC Department of Revenue.  

For help, use our online Claims Inquiry Form or contact your assigned claims specialist. You may also call our Claims Department at 1-800-893-6246, ext. 2455 (behavioral health, intellectual/developmental disability, and traumatic brain injury services), or ext. 2456 (physical health services).

Claims Payments 

Vaya pays approved “clean claims” within 30 calendar days after the date of receipt. 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 

All payments to network providers are processed through electronic funds transfer (EFT) according to our checkwrite schedule. If any approved claim is not paid within the required 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 information about overpayments and self-audits, please refer to our Provider Self-Audit Protocol for Paid Claims Audits and Provider Self-Audit Overpayment Summary. 

Claims Denials and Appeals 

Notifications of claim denials are provided by the RA or by other final notification of payment, payment denial, disallowance, payment adjustment, or notice of program or institutional reimbursement. Final notification occurs after all administrative actions by the provider, along with assistance from Vaya, have been applied to the claim in an attempt for the claim to be paid and the claim has denied, in whole or in part. 

All providers must submit requests for appeals (reconsiderations) of claims denials within 30 days of this final notification. For more information, visit our Provider Appeals page. 

Vaya claims specialists review denied claims daily and work internally to correct any system errors that may have caused a denial. These denials are then re-adjudicated by Vaya without action required from the provider. Claims specialists may contact providers to alert them of any other denials the provider needs to correct and resubmit. Claims specialists can answer questions related to topics such as: 

• Why a claim was denied 
• Meaning of reason codes 
• Denials due to no authorization when an authorization is present 
• Denials due to authorized units exceeded 
• Denials due to a combination of no coverage for patient/service/provider 
• How to replace (resubmit a corrected) claim 
• How to revert (void) a claim 
• How to locate RAs in the Provider Portal 
• Partial claim payments