Provider Getting Paid Claims Submission
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Claims Submission

Vaya Health offers three claims submission options for network providers, authorized billing agents, and health care clearinghouses: 

  • Through our secure Provider Portal using the CMS-1500 or UB-04 webforms (as appropriate to the service) 
  • Through Vaya’s secure file transfer protocol (SFTP) web portal (HIPAA-compliant 837I [Institutional] or 837P [Professional] EDI files). Please note we accept only .txt and x12 file formats. We do not accept .pdf or .xlsx files. 

All network and out-of-network providers must submit all claims electronically unless otherwise permitted by the provider’s contract with Vaya (or one of our subcontractors) or the Vaya Provider Operations Manual. 

Claims for Medicaid services must be filed by the provider and received by Vaya within 365 days of the date of service or, for inpatient claims and nursing facility claims only, the date of discharge. Claims for State-funded services must be filed and received within 90 days. All initial claims submitted past these deadlines will be denied (unless there is an applicable exception, for example, retroactive Medicaid eligibility) and cannot be resubmitted.

Network providers are encouraged to submit routine billings on a weekly or bi-weekly schedule in conjunction with our checkwrite schedule. 

For help, use our online Claims Inquiry Form or contact your assigned claims specialist. You may also call our Claims Department at 1-800-893-6246, ext. 2455 (behavioral health, intellectual/developmental disability, and traumatic brain injury services), or ext. 2456 (physical health services).

Basic benefit services, enhanced services, NC Innovations Waiver services, State-funded (Non-Medicaid) Residential Services, and other daily and periodic services must be submitted using the 837P format or, if billing through our Provider Portal, the electronic CMS-1500 form. 

Inpatient services, Therapeutic Leave, Medicaid Residential Services, hospital emergency department (ED)/outpatient revenue codes, and Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) services must be submitted using the 837I format or, if billing through the Provider Portal, the electronic UB-04 form. 

When a specific service is rendered multiple times in a single day, the service must be “bundled” by combining multiple units rather than billing separate line items. This will prevent a duplicate billing denial. 

To pay any provider, regardless of network status, Vaya must have the provider’s W-9 form on file. Vaya accepts paper claims from out-of-network providers in the following circumstances:

  • Claims for emergency and post-stabilization services.
  • Claims for continuity of care periods as defined by the North Carolina Department of Health and Human Services (NCDHHS). We accept paper claims in this circumstance only if the provider does not have a member-specific out-of-network agreement OR an out-of-network-enrollment with Vaya.

Out-of-network providers filing paper claims must submit an accurate CMS-1500 or UB-04 billing form containing the correct data elements. Vaya will not accept copies of these forms or handwritten forms.

Providers may deliver these materials in person or can mail them to Vaya Health, Attn: Claims, 200 Ridgefield Court, Suite 218, Asheville, NC 28806.

 

Network providers who wish to submit using an 837 file must complete training, successfully submit and receive test files, and execute a trading partner agreement.  

Detailed instructions for 837 file submission are provided in the HIPAA Transaction Professional (837P) and Institutional (837I) Transaction Companion Guides. Vaya provides the following HIPAA transaction files back to providers: 999 (an acknowledgment receipt), 277CA (claims status response), 824 (a line-by-line acceptance/rejection response), and human-readable Velocedi and submitter reports. These files are returned to the submitter’s SFTP Out/ folder within 30 minutes of file upload. 

Pharmacy providers are required to submit all claims electronically using up-to-date NCPDP standards. Pharmacies should use the following billing information to transmit claims:  

  • RxBIN: 610241  
  • RxPCN: RXVAYA  
  • RxGroup: Member-specific (see Medicaid ID card for details) 
  • Member ID: Member-specific (see Medicaid ID card for details) 

Within 14 calendar days after Vaya’s pharmacy benefit manager, Navitus Health Solutions, receives a clean claim or invoice from a provider for a pharmacy claim, Navitus will either approve or deny payment or determine that additional information is required to approve or deny the claim. Navitus pays approved pharmacy claims within 14 calendar days after the date of approval. The 14-day period includes the 14 days to determine if a claim can be paid or denied.  

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