When a Vaya Health Utilization Management Clinician is unable to approve a request based on medical necessity or Early and Periodic Screening, Diagnostic, and Treatment, the request is referred to a licensed, doctoral-level psychologist or physician for peer review.
The Peer Reviewer may contact the provider to obtain additional information. If the Peer Reviewer is unable to reach the provider, they will make a decision based on the information submitted with the service authorization request.
Peer-to-peer discussions
If Vaya issues a medical necessity denial, the ordering or attending provider may request a peer-to-peer discussion within three business days of the denial notice. If the Peer Reviewer who made the decision is not available, Vaya will make an equally qualified Peer Reviewer available.
Peer-to-peer discussions are not appeals. Rather, they provide an opportunity to discuss the decision and reasons for the denial. The member/recipient, or their legally responsible person, still has appeal rights and must file a formal appeal with Vaya to request that we overturn the denial. The provider may request an appeal on the member’s/recipient’s behalf if Vaya has their written consent for the provider to appeal the specific service authorization decision.