'; Network Participation | Vaya Health

Network Participation

Our policy is to develop and maintain a sufficient network of high-quality service providers that meets member and community needs within available resources. Network participation means that you are listed in the Vaya Health Network Directory and are eligible for referrals from Vaya. This does not include providers serving a member under an out-of-network agreement.

For more information, please refer to our Provider Operations Manual.

Vaya’s network providers are required to demonstrate cultural competency, use evidence-based and best practices, practice a commitment to care and treatment that improves member outcomes, adhere to ethical and responsible practices, robustly protect member rights and meet Vaya’s business, operational and network development needs. Vaya is committed to the achievement of positive outcomes for members, as well as member satisfaction. We depend on our network providers to offer high-quality services and demonstrate accountability for the wellbeing of our members.

Participation in the Vaya closed provider network is a privilege, not a right. We have established a fair, impartial, objective and consistent process for the enrollment and re-enrollment of network providers that complies with applicable federal and state laws, rules and regulations and the requirements of our Medicaid Waiver contract with NC Medicaid. You must be enrolled with NC Medicaid (as a Medicaid provider consistent with the agency’s disclosure screening and enrollment requirements) and with NCTracks before you can become a contracted provider in the Vaya network.

There is no right under federal or state law for any provider to participate in our closed provider network. The only exceptions are for emergency services or when there is no network provider available to provide medically necessary covered services to a particular individual. Additional information, including Vaya’s selection and retention criteria, is included in our Provider Operations Manual. You may also learn more on our Provider Advisory Council page.

Pursuant to 42 CFR § 447.15 and 10A NCAC 22J. 0106, it is unlawful and an unacceptable practice to knowingly demand or collect any reimbursement from a Medicaid beneficiary, his/her family or legally responsible person directly, except where permitted by law.

Access to Care

Federal regulations require Vaya to maintain a network of providers sufficient in number, mix and geographic distribution to meet the needs of the anticipated number of Medicaid beneficiaries in our catchment area. The N.C. Department of Health and Human Services (DHHS) monitors the adequacy of our network through the annual Community Mental Health, Substance Use and Developmental Disability Services Network Adequacy and Accessibility Analysis, also known as the Gaps Analysis. The Gaps Analysis includes objective measures, such as geo-mapping, to analyze service access and availability throughout our catchment area, as well as input from member, family, provider and stakeholder surveys.

Most services will be available within 30-45 miles or 30-45 minutes driving time. There is a walk-in center located in every county we serve. However, because of insufficient demand and economy-of-scale factors, some specialty providers may be located outside this radius, or there may only be one provider available to deliver the needed service. We are not required to contract with providers beyond the number necessary to meet the needs of our members.