Forms

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

Accepted Taxonomies for Behavioral Health Services

ALPHAMCS RA Steps to Export into Excel

ASAM Worksheet for Adolescents

ASAM Worksheet for Adults

Authorization and Release for Background Checks

Authorization for Release of Information

Calocus Scoresheet

Cans Assessment 0-4 Years Rating Sheet

Care Coordination Referral Form

Checkwrite Schedule

Claims Adjudication Codes and Actions

Clinical Practice Guidelines, Leveling Tools and HEDIS Measures

Community Guide b3 Waiver Service

Comprehensive Clinical Assessment

Credentialing Initiation Form

Criterion 5 Form

CSV RA Conversion Template

Developmental Therapy b3 Waiver Service

Diagnosis to Disability Crosswalks

Diversion Law Exception Worksheet

DMA Eliminated Taxonomy Crosswalk

Downloading And Importing Alphamcs Detail Files

EDI Enrollment Form

EPSDT Non Covered Services Request Form

Geriatric Team Referral Form

Getting Paid EFT Authorization Agreement for Automatic Deposit

High Volume Claim Inquiry Form

Individual Support Personal Care b3 Waiver Service

Innovations Out Of State Travel Form

Innovations Waiver Self Review Tool

Inpatient Concurrent Review Form

Insurance Requirements

Iris Incident Report Form

Locus Scoresheet

LTCS In lieu of Service Definition

Medicaid Covered Diagnoses

NC DMA Provider Satisfaction Survey Results

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 SAS

Non Medicaid Funded MH/DD/SA Service Definitions

Non Medicaid Funded MHSA Enhanced Service Definitions

Non Medicaid Funded Transition Management Services

Non Medicaid Residential Services Referral Profile

One Time Transitional Costs B3 Waiver Service

Peer Support B3 Waiver Service

Permanent Supportive Housing Referral Form

Physician Consultation B3 Waiver Service

Program Integrity incident Reporting Backup Staffing Form

Provider Change Request Form

Provider Manual

Provider Self Audit Over payment Workbook

Provider Self Audit Protocol For Paid Claims Audits

Psychological Testing Authorization Request Form

QM Annual Report full Report

Qm Annual Report program Description

Qm Annual Report program Evaluation

Qm Annual Report QM Work plan

Quarterly Provider Level I Incident Report

Regional Assessment and Referral Form RARF

Regional Referral Form

Registering And Selecting An Appropriate Taxonomy Code

Short Range Goal Template For NC Innovations Providers

Standard Rate Schedule – Medicaid 1915(b) and (b)(3)

Standard Rate Schedule Medicaid C

Standard Rate Schedule – Non-Medicaid

Supported Employment B3 Waiver Service

Universal Residential Placement Application

Vaya Health Tested Clearinghouses

Vaya Health Network Adequacy and Accessibility Analysis

External links

Getting paid

N.C. DHHS/DHB/DMH Resources

Network participation

Performance and quality

Additional resources