Prior Authorization
Vaya Health network providers must submit service authorization requests (SARs) electronically via the Vaya Provider Portal. This includes prospective, continuing, and retrospective authorizations.
For more information about which services require prior authorization, refer to our Authorization Guidelines. Providers are responsible for submitting a SAR for each service requiring authorization, supplying required documentation, and demonstrating medical necessity. Requests must include the name of the individual who is providing the service or who is most knowledgeable about the case, along with their telephone number.
Except for requests based on retrospective Medicaid eligibility, all SARs must have a service start date that is on or after the date of SAR submission.
For pharmacy authorization guidelines, visit our Pharmacy Prior Authorization page.
For assistance with authorization requests, contact Vaya’s Utilization Management (UM) Team at 1-800-893-6246, ext. 1513, or at UM@vayahealth.com. For help using the Vaya Provider Portal, call our Provider Support Service Line at 1-866-990-9712, Monday – Saturday, 7 a.m. – 6 p.m., including holidays.
Physical Health Services: Submit the following physical health SAR forms to Vaya via e-fax:
- Physical Health Outpatient SAR Form: 828-262-1859
- Physical Health Inpatient Admission Notification and SAR Form: 828-707-9356
- Post-Acute Facility SAR Form: 828-759-2161
For radiology, cardiology, durable medical equipment (DME), and outpatient specialized therapy, please contact our delegated subcontractor, EviCore, at 1-800-918-8924, ext. 24176, or evicore.com/provider.
For vision services, including medical/surgical procedures, contact Avēsis, LLC, at myavesis.com/contact-us.
Behavioral Health, Intellectual/Developmental Disability (I/DD), and Traumatic Brain Injury (TBI) Services: Submit the Behavioral Health Paper SAR Form to Vaya via e-fax:
- Outpatient services: 828-398-0571
- Inpatient services: 828-348-4141
Initial requests: SARs must be submitted at least 14 days (but no more than 30 days) prior to the requested start date of services, except for crisis, inpatient, or other expedited requests.
Continuing requests: SARs must be submitted at least 14 days before the end of the existing authorization (except for crisis, inpatient, or other expedited requests) to avoid a gap in authorization or payment. It is your responsibility to conduct a clinical review of the individual’s ongoing need for services.
Crisis and inpatient requests:
- Initial requests: Refer to SAR requirements for specific services on our Authorization Guidelines.
- Continued requests: SARs and supporting documentation must be submitted 24 hours prior to the lapse of the current authorization, unless the renewal date falls on a weekend or official Vaya holiday, when the request may be submitted the next business day for retrospective review.
Expedited requests: If you believe taking the time for a standard review could seriously jeopardize the individual’s life or health or ability to attain, maintain, or regain maximum function, you may request expedited processing in the electronic SAR. For Paper SARs, check the “Expedited request” box and provide clinical justification of the risk of harm in the “Reason for admission/ continued service or other comments/ justification” field.
- Routine (non-urgent) service reviews: Vaya will issue a decision and provide notice within 14 calendar days of receipt of the request.
- Expedited inpatient hospitalization reviews: Vaya will issue a decision and provide notice no more than 72 hours following receipt of the request.
- Expedited reviews of other services: Vaya will issue a decision and provide notice within 72 hours following acceptance of an expedited request. For requests to extend a current course of treatment that involves urgent (e.g., inpatient, facility-based crisis) care, Vaya will issue a decision and provide notice within 24 hours of receipt of the request (provided the request was received at least 24 hours before the expiration of the current authorization). Vaya 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.
Extensions
Routine services reviews may be extended up to 14 additional calendar days if a member/ recipient or provider requests an extension or UM staff justifies the need for additional information and how the extension is in the individual’s interest. In such cases, Vaya will send a written notice to the member/ recipient and provider before the expiration of the initial review timeframe that explains the reason for the extension and the date when we expect to make a decision. The notice informs the member/ 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/ recipient is given at least 45 calendar days from receipt of the notice to respond to the request for more information.
If Vaya fully or partially denies the request, notification includes:
- An indication of which coverage criteria were and not met
- The member’s/ recipient’s rights to and process for filing an appeal, including any right for continuation of services during the appeal process and how to request an expedited appeal
More information about appeals of authorization decisions, refer to our Provider Operations Manual.
Providers submitting the Paper SAR must include a print screen from NCTracks showing the eligibility determination date and only the necessary information from the medical record to fully justify the request to Vaya.
Inpatient Psychiatric Units: Complete and include the following documentation with the SAR:
Regional Referral Form (ADATC) or Regional Referral Form (State Psychiatric Hospital)
Alcohol and Drug Abuse Treatment Center (ADATC): For ADATC detox or rehabilitation services, fax a completed Regional Referral Form to 828-348-4141 and include a clinical assessment.
State Psychiatric Hospital: Fax a completed Regional Referral Form and assessment to Vaya’s Member and Recipient Services Department at 1-877-917-9887. Follow the same process for individuals referred to a State Psychiatric Hospital who are diagnosed with (or with a suspected diagnosis of) I/DD and a co-occurring mental health disorder.
Child and adolescent residential placement: To begin the process, submit a completed Universal Child Residential Placement Referral Form. This form is designed to help referring organizations or individuals streamline discharge planning and eliminate the time and redundancy associated with multiple organization-specific applications. Use of this form does not guarantee authorization of residential or other services. Responsibility for appropriate discharge from inpatient facilities remains with the discharging provider.