Vaya Health provides reimbursement for behavioral healthcare emergency and post-stabilization crisis services for our eligible Medicaid members at any time, without regard to prior authorization or whether the provider is contracted with Vaya.
We will cover Medicaid inpatient and outpatient “emergency services,” delivered by qualified providers, that are needed to evaluate or stabilize an “emergency medical condition” as defined at 42 CFR § 438.114(a).
We will also cover Medicaid “post-stabilization care services,” in accordance with 42 CFR § 438.114(e) and § 422.113(c) in limited circumstances. “Post-stabilization care” services generally means those covered services provided to maintain the stabilized emergency medical condition.
Medical treatment provided in an emergency department (ED) that is unrelated to behavioral health is the responsibility of N.C. DHHS. If you are unsure about whether a service should be billed to Vaya or to NC Medicaid, refer to the Hospital Mixed Services Payment Protocol, Medicaid Covered Diagnoses and Medicaid Covered Diagnoses: Special Populations.
For more information to enroll as a contracted provider of services, visit our Hospital Enrollment page.
Emergency services admission notification
If a Vaya member, or someone who you believe may be eligible for services covered by Vaya, presents at a hospital for emergency services or in a behavioral health crisis, the hospital must inform Vaya of the admission via a daily report to its designated Vaya point of contact and/or by calling Vaya Member Services at 1-800-849-6127. The ED or facility where the individual is receiving treatment is ultimately responsible for assessment and disposition of individuals in its care. Vaya care coordinators are available at most contracted facilities within our catchment area to provide ED staff with consultation, coordination with the individual’s Behavioral Health Clinical Home (BHCH) and education on appropriate treatment resources.
Hospitals must allow Vaya staff access to Vaya members while in the ED or post-stabilization crisis services to participate in diversion from inpatient admission when appropriate, discharge planning, bridging to outpatient service engagement, crisis planning or other appropriate activities. Likewise, if the member has a treatment relationship with a Vaya network provider, hospitals must allow that provider access to the member while receiving emergency services to help facilitate diversion from inpatient care.
You must notify Vaya within 24 hours when a Vaya member is discharged from emergency services. If the member is discharged, you must arrange for a follow-up appointment with the individual’s BHCH, or, if there is no BHCH, with an appropriate outpatient or other behavioral health provider within five business days of discharge. For help arranging the follow-up appointment, call Vaya Member Services at 1-800-849-6127.
Claims submission for emergency or post-stabilization crisis services
Vaya is responsible for paying for covered emergency services needed by our Medicaid members regardless of whether the provider that furnishes the services has a contract with us.
Requests for reimbursement for emergency or crisis stabilization services from providers must be presented to Vaya within 90 days of treatment or discharge. To submit a claim for emergency or post-stabilization crisis services, contracted providers should refer to our Claims Submission page.
Non-contracted providers may submit paper claims to Vaya Health, Attn: Claims and Reimbursement, 200 Ridgefield Court, Asheville, NC 28806. These providers are required to submit an accurate CMS-1500 or CMS-1450 (also known as UB04) billing form with correct data elements. A signed federal W-9 form must be submitted to Vaya before payment can be issued. Failure to submit all necessary documentation requested by Vaya means that the claim is not deemed to be a “clean claim” and therefore may result in the claim not being processed for approval or denial.
To ensure more accurate claims data entry, faster processing and electronic access to claims information, we encourage non-contracted providers to register to submit claims electronically using AlphaMCS. To sign up, follow the instructions on our AlphaMCS page.
You may not bill Medicaid members (or otherwise hold them liable for payment) for screening and treatment that was needed to diagnose an emergency medical condition or to stabilize the individual.