Forms

Looking for a form or document? You can view a list of forms and documents by clicking below or using the search in the upper right of this site. 

Please refer to the following forms, tools, and other resources to help you perform your functions as a network provider. For additional assistance, call 1-866-990-9712 or email provider.info@vayahealth.com. 

Alphabetical list of documents and forms

837i 5010 Data Clarification Manual

837p 5010 Data Clarification Manual

837p and 837i Steps For Testing and Approval

ASAM Worksheet for Adolescents

ASAM Worksheet for Adults

Authorization and Release for Background Checks

Authorization for Release of Information

CANS Assessment 0-4 Years Rating Sheet

NCDHHS Children with Complex Needs Settlement Referral

Claims Adjudication Codes and Actions

Clinical Practice Guidelines and Leveling Tools

Community Guide (b)(3) Waiver Service

Criterion 5 Form

CSV RA Conversion Template

Diversion Law Exception Worksheet

Downloading And Importing AlphaMCS Detail Files

EDI Enrollment Form

EFT Authorization Agreement for Automatic Deposit

Enrollment Initiation Form: Licensed Practitioner (LP)

EPSDT Non-Covered Services Request Form

Follow-Up After Emergency Department Visit for Mental Health

Geriatric Team Referral Form

Good Faith Contracting Policy

High-Volume Claim Inquiry Form

I/DD Bed Board – Residential Vacancy Reporting

Independent Assessment for Personal Care Services (PCS) (Start date: 30 days prior to Tailored Plan Launch)

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

Inpatient Concurrent Review Form

IRIS Incident Report Form

Job Aid: Provider Portal Security Access Administrator

Local Barriers Committee Request Form

Long Term Community Supports (LTCS) in lieu of Service Definition

Medicaid Covered Diagnoses

Medicaid Covered Diagnoses: Special Populations

Member-Specific Out-of-Network Agreement Request

NC Medicaid Provider Satisfaction Survey (2021)

Network Adequacy and Accessibility Analysis (2021)

Network Provider Participation Agreement

Network Provider Systems Access Administrator Designation

Non-Medicaid-Funded ACT Policy

Non-Medicaid-Funded Critical Time Intervention

Non-Medicaid-Funded Developmental Therapy Service

Non-Medicaid-Funded Facility-Based Crisis Child

Non-Medicaid-Funded Inpatient Behavioral Health Services

Non-Medicaid-Funded IPS-SE For AMH-ASA

Non-Medicaid-Funded MH/DD/SU Service Definitions

Non-Medicaid-Funded MHSU Enhanced Service Definitions

Non-Medicaid-Funded Transition Management Services

Non-Medicaid Residential Services Referral Profile

Non-UCR Invoice Template

Out-of-Network Enrollment Request Form

PCP Member Transfer Form Upload

PCS Assessment Request Form

Physician Consultation (b)(3) Waiver Service

Program Integrity Incident Reporting Backup Staffing Form

Provider-Based TCM Innovations Waiver Emergency Slot Form

Provider Contract Request Form

Provider Operations Manual

Provider Self-Audit Overpayment Workbook

Provider Self-Audit Protocol For Paid Claims Audits

Psychological Testing Authorization Request Form

Quarterly Provider Level I Incident Report

Rate Request – Enhanced Rate Budget Worksheet

Rate Request – Existing Service Rate Request

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

Regional Referral Form (ADATC)

Regional Referral Form (State Psychiatric Hospital)

Request for Claims Denial Appeal Review (Level 1)

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

Supported Employment (b)(3) Waiver Service

TBI Funding Request Form

TCL Community Monthly Update Form Link

TCM External Clinical Consultation Request

Universal Child and Adolescent Residential Placement Referral Form | En Español

Use of Antipsychotic Medications and Monotherapy (1/24/2020)

Vaya Health-Tested Clearinghouses

External links

Related to payment and billing

» ICD-10 Code Search

» NCTracks Website

N.C. DHHS/DHB/DMH Resources

» N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services

» NC Medicaid

» N.C. DHHS Person-Centered Planning forms

» Medicaid Clinical Coverage Policies

» N.C. Division of Health Benefits Clinical Coverage Policy No: 8P

» N.C. Division of Mental Health, Developmental Disability and Substance Use Services (DMH/DD/SUS) Service Definitions

» NC-SNAP (NC Support Needs Assessment Profile)

Network participation

» Letter of Support Request

» Provider Nomination Form

» Provider Operations Manual

» RaDSE DocuSign® Form

Performance and quality

» AFL Update Form

» Fraud Prevention Toolkit

» Incident Response Improvement System

» NC-TOPPS website

» N.C. Department of Health and Human Services (DHHS)

» N.C. DHHS Agency Monitoring Tools for Providers

» N.C. DHHS Audit Information

» N.C. DHHS Consumer Perceptions of Care reports

» N.C. DHHS Monitoring Changes FAQ

» N.C. DHHS Home and Community Based Settings (HCBS) Self Assessment (Paper Version)

» N.C. DHHS New Unlicensed Site Review Tool for Providers

» N.C. DHHS Review Tool for LIPs/ Group Practices and Agencies Billing Outpatient Services Only

» N.C. DHHS Unlicensed AFL Review Tool for Provider