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 Child 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 
>> Self-Review of Innovations Member Record Job Aide
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)
Network Adequacy and Accessibility Analysis (2019)
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 
Quarterly Provider Level I Incident Report 
Regional Assessment and Referral Form (RARF) 
Regional Referral Form 
Registering And Selecting An Appropriate Taxonomy Code 
Request for Claims Denial Reconsideration (Level 1)
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 
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. 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 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 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

 

Additional resources

» Guardianship Roles of MHDDSA Providers

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

» NC Medicaid