Program Integrity

Vaya Health is committed to monitoring provider performance, ensuring the integrity of our Medicaid managed care program and promoting the provision of high-quality services to our members. Vaya staff in the Network Performance and Integrity Department conduct multiple provider oversight functions, including:

  • Responding to allegations of fraud, waste and abuse
  • Referring suspected fraud to NC Medicaid for potential civil and/or criminal investigation by the Medicaid Investigations Division of the N.C. Department of Justice
  • Auditing and investigating claims and service documentation
  • Tracking, reviewing and reporting self-audits
  • Conducting site and unlicensed alternative family living reviews
  • Conducting complaint investigations, focused monitoring reviews and post-payment routine monitoring reviews
  • Conducting health and safety investigations
  • Referring complaints, grievances and investigations for licensed facilities to the N.C. Division of Health Service Regulation or the applicable oversight agency in other states
  • Conducting three-way hospital quarterly reviews
  • Monitoring providers’ contractual provisions, including scopes of work and performance-based indicators
  • Tracking, gathering follow-up information and coordinating the review of incidents filed by providers in the state’s Incident Response Improvement System (IRIS)
  • Conducting post-payment reviews of services that are not pre-authorized
  • Providing technical assistance to providers

Need Help?

Finding care can be confusing sometimes. At Vaya Health, we make it easier. The process starts with a phone call to our Access to Care Line at
1-800-849-6127.