Hospitals are essential providers in the continuum of care. Vaya Health works with hospitals to coordinate member care, ensure successful discharge planning, reduce readmittance rates, and help members transition to local, community-based treatment settings.
Coordination of care and discharge planning
Coordination of care and discharge planning begin at the time of the initial assessment and are an integral part of every member’s treatment plan. Please note:
- Hospitals must schedule treatment and discharge planning meetings for members within 24 hours of admission.
- Hospitals must notify Vaya and a member’s primary care provider (PCP), behavioral health provider(s), and/or Peer Bridger at least 24 hours prior to the intended date and time of any discharge.
- Hospitals must work collaboratively with Vaya for effective, timely discharge planning beginning at admission and throughout the discharge planning process as needed. Prior to discharge, hospitals must work with Vaya and the member to coordinate any discharge planning meetings with the member’s designated PCP, behavioral health home, and Care Manager/Care Coordinator.
- Once the discharge date is determined, hospitals must call the member’s PCP, behavioral health provider(s), community health service provider, or the Vaya Member and Recipient Service Line at 1-800-962-9003 to schedule a follow-up appointment to occur within seven days of discharge with the PCP (for physical health admissions) or within five days of discharge (for behavioral health admissions).
- Medicaid members should not be discharged with prescriptions for medications that are not covered by NC Medicaid.
Hospital reimbursement
We reimburse contracted hospitals that provide covered, medically necessary health care services across North Carolina and in neighboring states based on the NC Medicaid published fee schedules. We also reimburse providers for covered Medicaid emergency and crisis stabilization services.
For more information about covered services, please refer to the Mixed Services Payment Protocol, Medicaid Covered Diagnoses, Medicaid Covered Diagnoses: Special Populations, and the NC Medicaid Program Specific Clinical Coverage Policies.
If you are a Vaya network provider contracted for inpatient, enhanced, and/or outpatient services, visit our Authorization Guidelines page for information on how to submit service authorization requests (SARs). You must notify Vaya of any inpatient admission of a Vaya member within 48 hours of admission.
While you are granted a short “pass-through” period, we encourage you to submit the SAR in the Vaya Provider Portal within 48 hours of admission. If applicable, also submit the Regional Referral Form (ADATC) or Regional Referral Form (State Psychiatric Hospital) within 48 hours of admission. If the stay exceeds seven days, authorization is required starting on day eight.
We reserve the right to deny authorization and reimbursement of the initial pass-through period if you fail to notify us of the individual’s admission within the 48-hour time frame. Failure to submit timely SARs may result in denial of reimbursement for non-covered service days.
For additional information and guidance, refer to the Vaya Provider Operations Manual and your Vaya Hospital Network Provider Participation Agreement.
If you are not a Vaya network provider and are delivering emergency or post-stabilization crisis services to Vaya members, you must enter into an Out-of-Network Agreement to be reimbursed for medically necessary covered services. Learn more on our Hospital Enrollment webpage or contact Vaya’s Utilization Management Team at 1-800-893-6246, ext. 1513, to initiate the process.
If all criteria for a continued acute stay in an inpatient psychiatric facility as specified in 10A NCAC 25C .0302 are not met for Medicaid members age 17 and younger, Vaya may authorize continued stay in an inpatient psychiatric facility at a post-acute level of care to be paid at the established residential rate if the facility and program services are appropriate for the member’s treatment needs and all of Criterion 5 conditions are met.