Vaya Health maintains a data-driven provider monitoring and performance improvement program to ensure services billed meet quality and regulatory standards, promote member safety, and maintain provider accountability. All providers delivering services to Vaya members and recipients are subject to monitoring to ensure consistent delivery of high-quality care.
Monitoring activities may include announced or unannounced onsite visits and desk reviews. The monitoring activities may include, but are not limited to:
- Clinical quality reviews
- Complaint/grievance investigations
- Compliance and policy reviews
- Focused provider monitoring
- NC Innovations Waiver-specific monitoring, including Home Modifications and Individual and Family Directed Services (Employer of Record and Agency with Choice models)
- Monitoring of fidelity for specific services
- Quality of care and member health and safety
- Tailored Care Management (TCM) performance reviews
- Trend-related monitoring based on significant indicators and/or reported trends that may impact quality services, as well as federal and state block grant review
Vaya provides written notification to providers prior to initiating monitoring activities, except in cases involving health and safety reviews or investigations, where notification occurs onsite. Prior to monitoring, Vaya provides a copy of the review tool. We conduct opening and exit summary conferences when applicable.
Investigations and monitoring activities may result in a Plan of Correction and/or a referral to the Special Investigations Unit.
Review tools
View the Sample Routine Provider Quality Improvement Review Tool. For more information about monitoring of agencies, review the NCDHHS FAQ.
Since July 1, 2018, licensed independent practitioners (LIPs), group practices, and agencies billing outpatient services are monitored only using the NCDHHS Review Tool for LIPs, Group Practices and Agencies Billing Outpatient Services Only (formerly known as the Post-Payment Review Tool for LIPs).
Reviews will continue on a two-year cycle. The updated process does not diminish or reduce Vaya’s responsibility or authority for oversight and monitoring of network providers.
Unlicensed AFL reviews are health and safety reviews of unlicensed community-based private homes. These reviews occur annually for Innovations Waiver participants and every two years for recipients of State-funded services.
View the NCDHHS Unlicensed AFL Review Tool for Providers. To add or change AFL home information, use Vaya’s AFL Update Form.
This annual review ensures compliance with the requirements of the Substance Use Prevention and Treatment Block Grant and Community Mental Health Services Block Grants. Block grant monitoring consists of a review of multiple programs. It also includes record reviews for specific service requirements.
Vaya network providers of mental health and substance use disorder services are required to participate in the NC Treatment Outcomes and Program Performance System (NC-TOPPS) system. NC-TOPPS interviews collect vital information about the people served by North Carolina’s behavioral health service system. Providers are required to maintain a 90% compliance rating on submission of NC-TOPPS interviews as outlined on the NC-TOPPS website.
Complete Vaya’s NC-TOPPS Online Training in Vaya Learn Portal below to learn more.