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

Authorization Guidelines »

» Medicaid 1915(b) Authorization Guidelines for Adult Mental Health/Substance Use Services

» Medicaid 1915(b) Authorization Guidelines for Adult Mental Health/Substance Use Services

» Medicaid 1915(b) Authorization Guidelines for Acute Services

» Medicaid 1915(b) Authorization Guidelines for IDD Non-Innovations

» Medicaid (b)(3) Authorization Guidelines for Adult and Child Mental Health/Substance Use

» Medicaid (b)(3) Authorization Guidelines for Non-Innovations Intellectual/Developmental Disabilities Services

» Non-Medicaid Authorization Guidelines for Adult Mental Health/Substance Use Services

» Non-Medicaid Authorization Guidelines for Intellectual/Developmental Disabilities Services

» Non-Medicaid Authorization Guidelines For Child Mental Health/Substance Use Services

CALOCUS Scoresheet

CANS Assessment 0-4 Years Rating Sheet

Care Coordination (Management) Referral Form

Checkwrite Schedule (2020)

Claims Adjudication Codes and Actions

Clinical Practice Guidelines, Leveling Tools and HEDIS Measures

Community Guide (b)(3) Waiver Service

Comprehensive Clinical Assessment

Credentialing Initiation Form

Criterion 5 Form

CSV RA Conversion Template

Developmental Therapy (b)(3) Waiver Service

Diagnosis to Disability Crosswalks

Diversion Law Exception Worksheet

Downloading And Importing AlphaMCS Detail Files

EDI Enrollment Form

EFT Authorization Agreement for Automatic Deposit

EPSDT Non-Covered Services Request Form

Geriatric Team Referral Form

High-Volume Claim Inquiry Form

Individual and Family Directed Services Handbook

Individual Support Personal Care (b)(3) 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

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

Medicaid Covered Diagnoses

NC Medicaid Provider Satisfaction Survey (2018-19)

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 (b)(3) Waiver Service

Peer Support (b)(3) Waiver Service

Permanent Supportive Housing Referral Form

Physician Consultation (b)(3) Waiver Service

Program Integrity Incident Reporting Backup Staffing Form

Provider Change Request Form

Provider Operations Manual

Provider Self-Audit Overpayment Workbook

Provider Self-Audit Protocol For Paid Claims Audits

Psychological Testing Authorization Request Form

Quality Management Annual Report – Full Report

Quality Management Annual Report – Program Description

Quality Management Annual Report – Program Evaluation

Quality Management Annual Report – QM Workplan

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 N.C. Innovations Providers

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

Standard Rate Schedule – Medicaid C

Standard Rate Schedule – Non-Medicaid

Supported Employment (b)(3) Waiver Service

Universal Residential Placement Application

Vaya Health-Tested Clearinghouses

Vaya Health Network Adequacy and Accessibility Analysis

External links

Related to payment and billing

» ICD-10 Code Search

» NCTracks Website

N.C. DHHS/DHB/DMH Resources

» 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 Abuse Services (DMH/DD/SAS) Approved Service Definitions

» N.C. DMH/DD/SAS Mental Health and Substance Abuse Enhanced Services

Network participation

» Letter of Support Request

» Out-of-Network Agreement Request

» Provider Advisory Council

» 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 New Unlicensed Site Review Tool for Providers

» N.C. DHHS Provider Satisfaction Survey 2017

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

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

» Provider Self Audit Over payment Workbook
Provider Self Audit Protocol For Paid Claims Audits

Additional resources

» Guardianship Roles of MHDDSA Providers

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