Vaya Health requires prior authorization for some services before providers can deliver them. To request prior authorization, providers should submit a service authorization request (SAR) through the Provider Portal (coming soon). For more information about which services require prior authorization, please refer to our Authorization Guidelines.
Vaya’s Utilization Management (UM) team reviews service authorization requests and makes decisions based on medical necessity and, for state-funded and Medicaid (b)(3) services, the availability of funding. When reviewing medical necessity, UM staff consider member or recipient needs, Medicaid waiver and clinical coverage policy requirements, federal regulations, clinical practice guidelines (if applicable), and EPSDT requirements (for Medicaid beneficiaries under age 21). Vaya does not offer any type of incentive for UM staff to deny, limit, or discontinue medically necessary services.
If a Vaya UM clinician is unable to authorize a requested service, it is referred to Peer Review. Only Vaya peer reviewers can deny or limit a service request. Providers have the option to have a peer-to-peer conversation with a Vaya peer reviewer to discuss their decision.
Prior Authorization Review Process
- For routine service reviews, UM will issue a decision and provide notice to approve or deny non- urgent service authorization requests within 14 calendar days of receipt of the request for services.
- For expedited inpatient hospitalization reviews, UM will make a decision and provide notice no more than 72 hours following receipt of the request.
- For expedited reviews of other services, UM will issue a decision to approve or deny a service within 72 hours after it accepts an expedited request. For requests to extend a current course of treatment that involves urgent (e.g., inpatient, facility-based crisis) care, UM will issue a decision within 24 hours of receipt of the request (provided the request was received at least 24 hours before the expiration of the current authorization). UM will issue a decision within 72 hours of receipt of the request if the request was received less than 24 hours before the expiration of the current authorization.
Prior Authorization Extensions
Deadlines may be extended up to 14 additional calendar days if a member or recipient requests an extension, the provider requests an extension, or UM justifies the need for additional information and how the extension is in the member’s or recipient’s interest. In such cases, Vaya will send a written notice to the member/recipient and provider prior to the expiration of the initial review timeframe, explaining the circumstances requiring the extension and the date when Vaya expects to make a decision. The notice informs the member or recipient of the right to file an appeal if they disagree with this decision.
If the member/recipient or provider fails to submit necessary information to decide the case, the notice of extension describes the information that is needed, and the member or recipient is given at least 45 calendar days from receipt of the notice to respond to the request for more information.
Pharmacy Prior Authorization Submission Process
If you have questions about Medicaid medication coverage or prior authorization, please contact the Pharmacy Service Line (1-800-540-6083).
Vaya’s delegated Pharmacy Benefits Manager (PBM) reviews and makes decisions for medication requests based on medical necessity guidelines and other statutory and regulatory standards. Vaya offers an electronic portal and review system for pharmacy UM request submission, but requests may also be submitted via phone (1-800-540-6083), fax (1-855-668-8553), or U.S. mail:
Navitus Health Solutions LLC
Attn: Prior Authorizations
1025 West Navitus Drive
Appleton, WI 54913
Pharmacy UM requests are processed, and prescribers notified of the determinations, within 24 hours after receipt of the request, except for requests for which the review cannot be completed due to insufficient information. In these cases, the PBM pends the request and requests the needed information within 24 hours after receipt of the request. Once the additional information is received, the PBM completes its review within 24 hours after receipt of that information.
Vaya allows coverage for a 72-hour supply of a medication in emergency situations where the medication could not otherwise be dispensed due to a prior authorization requirement. Vaya does not require a pharmacy to dispense this 72-hour supply if the dispensing pharmacist believes that the prescription presents a risk to the member, and if the pharmacist has made good faith efforts to contact the prescriber about it. Vaya covers consecutive 72-hour supplies if the prescriber has not completed the review or if the pharmacist has not been able to contact the prescriber to complete the requested review.
Decision Notification and Appeals
If Vaya or the PBM decides to deny coverage of a requested service, supply, or medication in its entirety or cover an amount or duration less than requested, notification includes:
- An indication of which coverage criteria for the request were and were not met
- The member’s rights to, and process for filing, an appeal or grievance. This includes the member’s right for continuation of coverage while an appeal is being resolved, information about requesting an expedited appeal, and a copy of the Appeal Request Form. The member’s right to request and be provided, free of charge, access to and/or copies of all information and documentation used in making the coverage determination
- More information about the appeals process can be found on our Appeals page.