Remittance advice and claims inquiries
The remittance advice (RA) and electronic 835 (for claims submitted using Electronic Data Interchange files) are standard methods of communicating to providers how each claim has been adjudicated. RAs are available in the download option of the Provider Portal following each checkwrite. RAs report whether claims are approved, denied, or recouped and the reason code for each adjudication.
Network providers are directly responsible for managing accounts receivable. 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 the North Carolina Department of Revenue.
For help, use our online Provider Service Desk Form, contact your assigned Vaya Claims Specialist, or call the Claims Department at 1-800-893-6246, ext. 2455 (behavioral health), or ext. 2456 (physical health).
Claims payments
Vaya processes and pays claims in accordance with the NC Medicaid prompt pay timeframes outlined in Vaya’s contract with NC Medicaid and federal law as follows:
- Medical claims (physical and behavioral health): Within 18 calendar days after receiving a clean claim or invoice from a provider for a medical claim, Vaya either approves or denies payment or determines additional information is required for approval or denial. Vaya pays approved medical claims within 30 calendar days of the approval date. The 30 days includes the first 18 days to determine if a claim can be paid or denied.
- Pharmacy claims: Within 14 calendar days after receiving a clean claim or invoice from a provider for a pharmacy claim, Vaya either approves or denies payment or determines additional information is required for approval or denial. Vaya pays approved pharmacy claims within 14 calendar days of the approval date. The 14 days includes the first 14 days to determine if a claim can be paid or denied.
A “clean claim” is a claim for a covered service that meets all the following criteria:
- Can be processed without obtaining additional information from the provider or from a third party
- Is timely received by Vaya
- Is on a completed, legible CMS-1500 form or UB-04 form or electronic equivalent
- Is true, complete, and accurate, and not a claim from a provider who is under investigation for fraud or abuse, a claim under review for medical necessity, a claim subject to coordination of benefits, or a claim that cannot be successfully processed through the NCDHHS MCIS as an encounter
All payments to network providers are processed through electronic funds transfer (EFT) according to our checkwrite schedule. If a provider is not signed up for EFT, payments will be mailed via paper check. If Vaya fails to pay any approved clean claim within the required time period, we must pay the provider interest, which is accrued at the annual rate of 18% of the claim amount beginning on the date following the day on which the payment should have been made. The total accrued interest amount is remitted to the provider when the claim is finalized and reimbursed on the checkwrite.
For information about overpayments and self-audits, please refer to our Provider Self-Audit Protocol for Paid Claims Audits and Provider Self-Audit Overpayment Workbook.
Claims denials and appeals
Notifications of claim denials are provided by the RA or by other final notifications of payment, payment denial, disallowance, payment adjustment, or notice of program or institutional reimbursement. Final notification occurs after all administrative actions by the provider, along with assistance from Vaya, have been applied to the claim in an attempt for the claim to be paid and the claim has denied, in whole or in part.
All providers must submit requests for appeals (reconsiderations) of claims denials within 30 days of this final notification. For more information, visit our Provider Appeals page.
Vaya Claims Specialists review denied claims daily and work internally to correct any system errors that may have caused a denial. Vaya re-adjudicates these denials without action required from the provider. Claims Specialists may contact providers to alert them of any other denials they need to correct and resubmit. Claims Specialists can answer questions related to topics such as:
- Why a claim was denied
- Meaning of reason codes
- Denials due to no authorization when an authorization is present
- Denials due to authorized units exceeded
- Denials due to a combination of no coverage for member/service/provider
- How to replace (resubmit a corrected) claim
- How to revert (void) a claim
- How to locate RAs in the Provider Portal
- Partial claim payments