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Forms

Looking for a form or document? View the categories below or use the search feature in the upper right corner to find what you need.

For assistance, call 1-866-990-9712 or email provider.info@vayahealth.com.

Network Participation

» Authorization and Release for Background Checks

» Enrollment Initiation Form: Licensed Practitioner (LP)

» Letter of Support Request

» Member-Specific Out-of-Network Agreement Request

» Network Provider Systems Access Administrator Designation

» Provider Contract Request Form

Claims and Billing

» 837i 5010 Data Clarification Manual

» 837p 5010 Data Clarification Manual

» 837p and 837i Steps For Testing and Approval

» Claims Adjudication Codes and Actions

» CSV RA Conversion Template

» EDI Enrollment Form

» EFT Authorization Agreement for Automatic Deposit

» High-Volume Claim Inquiry Form

» ICD-10 Code Search

» Non-UCR Invoice Template

» Provider Hardship Advance Request Form

» Provider Self-Audit Overpayment Workbook

» Provider Self-Audit Protocol For Paid Claims Audits

» Rate Request – Enhanced Rate Budget Worksheet

» Rate Request – Existing Service Rate Request

» Rate Request – Member- and/or Recipient-Specific Rate Request

» Request for Claims Denial Appeal Review (Level 1)

» Vaya Health-Tested Clearinghouses

Authorizations and Referrals

» Criterion 5 Form

» Diversion Law Exception Worksheet

» EPSDT Non-Covered Services Request Form

» Forensic Assertive Community Treatment (FACT) Referral Form

» HEART Team Referral Form (formerly Geriatric Team)

» Inpatient Concurrent Review Form

» Medicaid Covered Diagnoses

» Medicaid Covered Diagnoses: Special Populations

» NCDHHS Children with Complex Needs Settlement Referral

» Non-Medicaid Residential Services Referral Profile

» Non-Medicaid Residential Services Status Update

» PCS Assessment Request Form

» Psychological Testing Authorization Request Form

» Regional Referral Form (ADATC)

» Regional Referral Form (State Psychiatric Hospital)

» TBI Funding Request Form

» TCM External Clinical Consultation Request

» Universal Child and Adolescent Residential Placement Referral Form | En Español

Clinical Tools

» ASAM Worksheet for Adolescents

» ASAM Worksheet for Adults

» CANS Assessment 0-4 Years Rating Sheet

» Clinical Practice Guidelines and Shared Decision-Making Tools

» Initial Level of Care Eligibility Determination: ICF/IID

Incident Reporting

» Backup Staffing Form

» IRIS Incident Report Form

» Quarterly Provider Level I Incident Report

Miscellaneous Forms

» AFL Update Form

» Authorization for Release of Information

» Authorization for Release of Information | Spanish Version

» Member Continuity of Care Request Form

» I/DD Bed Board – Residential Vacancy Reporting

» PAC Barrier Committee Submission Form

» PCP Change Request Form

» PCP Member Transfer Form

» TCL Community Inclusion Monthly Update Form

NC Innovations Waiver

» Initial Level of Care Eligibility Determination: NC Innovations Waiver

» Innovations Freedom of Choice Acknowledgement

» Innovations Out-Of-State Travel Form Out-of-State Travel Common Questions and Answers

» Innovations Waiver Health Plan Transfer Form

» Innovations Waiver Participant Responsibilities

» NC Innovations Provider Quarterly Self Review of Member Record

» Self-Review of Innovations Member Record Job Aid

» Provider-Based TCM Innovations Waiver Emergency Slot Form

» RaDSE DocuSign® Form

» Short-Range Goal Template For N.C. Innovations Providers

NCDHHS Forms

» NC DHHS Person-Centered Planning forms

» NC-SNAP (NC Support Needs Assessment Profile)

» NC DHHS Agency Monitoring Tools for Providers

» NC DHHS Home and Community Based Settings (HCBS) Self Assessment (Paper Version)

» NC DHHS Provider Review Database

» NC DHHS Review Tools for LIPs