As a network provider, you (or your authorized billing agent or health care clearinghouse) must submit all claims through our AlphaMCS Provider Portal or through a HIPAA-compliant 837 EDI file unless your contract specifically states an alternative method. We do not accept paper claims from network providers.
When a specific service is rendered multiple times in a single day, the service must be “bundled” by combining multiple units rather than billing separate line items. This will prevent a duplicate billing denial. As required by law, we accept only HIPAA-compliant transactions:
- Basic benefit services, outpatient therapy, enhanced services, Innovations Waiver services and non-Medicaid residential and other daily and periodic services must be submitted using the ANSI 837P (professional) format or, if billing through AlphaMCS, the electronic CMS1500 form.
- Inpatient, therapeutic leave, Medicaid-funded residential services, outpatient revenue codes and ICF-IID services must be submitted using the ANSI 837I (institutional) format or, if billing through AlphaMCS, the electronic UB04 form.
- Paper claims are accepted only from out-of-network emergency and crisis services providers. These providers are required to submit an accurate CMS1500 or UB04 billing form with correct data elements. Paper claims may be mailed to Vaya Health, Attn: Claims and Reimbursement, 200 Ridgefield Court, Suite 206, Asheville, NC 28806.
Network providers are encouraged to submit routine billings on a weekly or bi-monthly schedule in conjunction with our checkwrite schedule. Claims must be submitted within 90 days of the date of service or discharge. Claims in which Vaya is the secondary payor must be submitted within 90 days of the date of denial from the first- or third-party payor.
In the case of retroactive Medicaid eligibility, the timely filing requirement of 90 days will be measured from the date that member eligibility is determined by DHHS and not from the effective date of eligibility, unless the notification occurs less than 45 days from the date of service. Claims submitted outside of these timeframes will be denied.
Network providers who wish to submit using an 837 file must complete training, successfully submit and receive test files and execute a trading partner agreement.
Detailed instructions for 837 file submission are provided in the HIPAA Transaction Professional (837P) and Institutional (837I) Transaction Companion Guides. Vaya provides the following HIPAA transaction files back to providers: 999 (an acknowledgment receipt), 824 (a line by line acceptance/rejection response) and 835 (an electronic version of the remittance advice).
The remittance advice (RA) is the standard method of communicating back to providers how each claim is adjudicated. RAs are available in the download option of AlphaMCS following each checkwrite. RAs report whether claims are approved, denied or recouped and the reason code for each adjudication.
Claims status inquiries should be directed to your assigned Vaya claims specialist or other Claims and Reimbursement Department staff at 1-800-893-6246, ext. 2455, or firstname.lastname@example.org.
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 N.C. Department of Revenue.