Authorization Information

For information on the service authorization request (SAR) process, visit our Prior Authorization page.

Vaya Health’s Utilization Management (UM) Team reviews SARs and makes decisions based on medical necessity and, for State-funded services, the availability of funding. When reviewing medical necessity, UM staff consider member/ recipient needs, Medicaid waiver and clinical coverage policy requirements, State-funded service definitions, 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.

Not all services require prior authorization. For more information, please refer to our Authorization Guidelines page. If a Vaya UM clinician is unable to authorize a requested service, it is referred to Peer Review.

Behavioral Health Clinical Practice Guidelines

All UM decisions and coverage of behavioral health, intellectual/developmental disability, and traumatic brain injury service decisions are consistent with Vaya’s Clinical Practice Guidelines, Leveling Tools and HEDIS Measures. Clinical practice guidelines are designed to guide providers on how to follow national and community standards of practice. The guidelines are not a substitute for the advice of a health care professional or the UM reviewer or peer reviewer making medical necessity determinations.

Vaya adopts guidelines that are based on valid and reliable clinical evidence (evidence-based practices) or a consensus of licensed professionals. We also may adopt clinical practice guidelines promulgated by nationally recognized peer review organizations such as the American Psychiatric Association (APA), the American Academy of Child Psychiatrists (AACAP), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Veterans Administration (VA), the Center for Child and Family Health, the British National Institute for Health and Clinical Excellence, the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Mental Health (NIMH), and the National Center on Birth Defects and Developmental Disabilities.