At Vaya Health, we work continuously to improve and standardize our business functions to effectively manage Medicaid, federal block grant, state and local funding. We are committed to building strong relationships with our network providers and ensuring claims are processed and paid in an accurate and timely manner.
Prior to claims submission, please be sure that you submit a Vaya Health EFT Authorization Agreement for Automatic Deposit, and read our billing and authorization requirements.
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- Enrollment and member ID: Members must be eligible for and enrolled in a Vaya Health Plan for a claim to be processed. The member ID number identifies the member receiving the service and is assigned by the AlphaMCS information system. The member must be successfully enrolled in a Vaya Health Plan for the provider to obtain this number. Claims submitted with incorrect member ID numbers or for members whose enrollment is no longer active will be denied.
- Medical necessity: All services paid with public funds must meet documented medical necessity criteria.
- Prior authorization: Certain services must be authorized by Vaya prior to service delivery and claims submission. Vaya’s claims adjudication system is specifically designed to verify authorization and other eligibility edits prior to reimbursement.
- Coordination of benefits: Vaya is the payor of last resort. All other available first- and third-party payment must be exhausted prior to billing Vaya for services rendered. If the member is eligible, state funds must be exhausted prior to billing Medicaid.
- NPI (National Provider Identifier) and taxonomy: All providers are required to obtain an NPI number to submit billing on the CMS1500 and UB04 forms. Best practice for successful claims submission is to obtain a separate NPI number for each site from which services are billed. Accurate NPI numbers and taxonomy codes are required for claims to be accepted and processed. Failure to comply with these guidelines may result in denied claims and/or recoupment of previously paid claims.
- NCTracks: Network providers are responsible for ensuring that provider names, billing addresses, site addresses, NPI numbers and taxonomy information submitted to Vaya are verified to be accurate and exactly match the information in the state of North Carolina’s Medicaid Management Information System (MMIS), known as NCTracks. Failure to adhere to this requirement may result in claims denial or recoupment.
- Documentation and service delivery requirements: Network providers are responsible for ensuring services are delivered and documented in accordance with controlling authority outlined in your contract, including, but not limited to, NC Medicaid Clinical Coverage Policies and the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) Records Management and Documentation Manual, APSM 45-2. Please be aware that Medicaid regulations do not allow payment for services delivered to inmates of public correctional institutions or for people admitted to facilities with more than 16 beds that are classified as Institutions of Mental Diseases (IMDs). This may include some state facility, private hospital, adult care home and family care home settings. It is your responsibility to know whether a member is admitted to an IMD at the time of service delivery.
- “Clean claims” requirement: A “clean claim” is defined at 42 CFR § 447.45 as one that can be processed without obtaining additional information from the service provider or from a third party. It includes a claim with errors originating in Vaya’s claims system. It does not include a claim from a provider under investigation for fraud or abuse or a claim under review for medical necessity. It is your responsibility to ensure that all claims submitted to Vaya meet this definition.
- Electronic funds transfers (EFTs): All reimbursement to network providers is done through EFT. Vaya does not write paper checks to network providers. It is your responsibility to ensure Vaya has accurate EFT, tax ID and W-9 information on file prior to claims submission. For further EFT assistance, please contact our Financial Operations and Reporting Department at SMC.Payables@vayahealth.com or at 1-800-893-6246, ext. 1112.
Please note: Authorizations must include the appropriate site where the service is performed to match the claim submission. If this Is not completed, a claim denial or recoupment will occur.
- Date of service (DOS): Each authorization will contain a unique number, start date and end date. Only claims with dates of service within these specific time frames will be paid. Dates and/or units outside these parameters will be denied.
- Type or code: Each authorization will indicate the specific service or service code that is authorized. Each service will be validated against the authorization to ensure the service billed matches the service authorized. Claims that fall outside of these parameters will be denied.
- Units: Each authorization will indicate the maximum number of units of service authorized for the time period in question. As each claim is being processed, the system will check to make sure the units claimed fall within the units of services authorized. The system will deny any claims that exceed the limits. Network providers must establish internal procedures to monitor units of service against authorizations to avoid claim denial due to exceeding units of service.
- Exceptions: Certain services do not require authorization at all or do not require an authorization for an initial service period, referred to as the “pass-through” period. These services are limited in scope, and the pass-through limits are applied per member, not per provider. Once the pass-through limit is reached for a member, all claims submitted without an authorization will be denied. Network providers must remain aware of this issue to avoid denied claims.