All providers offering services to Vaya Health members are subject to monitoring to ensure the delivery of high-quality services to our members. Our Network Performance Unit conducts various types of provider monitoring, including emergency health and safety reviews, routine post-payment reviews, initial (and routine) unlicensed Alternative Family Living (AFL) site reviews, initial credentialing (and recredentialing) site reviews, focused monitoring, complaint-based investigations, annual systems reviews and NC-TOPPS reviews.
Please note that investigations and monitoring activities could result in a plan of correction and/or a referral to the Special Investigations Unit.
Tools for specific reviews are listed below.
Provider agencies that are nationally accredited and licensed facilities that are monitored annually by the N.C. Division of Health Service Regulation (DHSR) are reviewed by Vaya at a minimum of every two years, using the Post-Payment Review Tool ONLY.
Provider agencies nationally accredited two years or more are required to deliver a copy of the official notification (e.g. letter, memorandum, certificate, etc.) from the agency’s accrediting body within 30 days of receipt. Provider agencies that receive only a provisional or one-year accreditation must submit all findings of the accrediting body to Vaya within 30 days of receipt.
Failure to maintain any required national accreditation may result in an adverse action, up to and including revocation of credentialing and termination of contract.
For more information related to the monitoring of agencies, view the DHHS FAQ.
Since July 1, 2018, licensed independent practitioners (LIPs)/group practices and agencies billing outpatient services only are monitored using the DHHS Review Tool for LIPs/Group Practices and Agencies Billing Outpatient Services Only (formerly known as the DHHS 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 our provider network.
Vaya conducts required site reviews upon initial provider credentialing and upon recredentialing. For information, please review the DHHS New Unlicensed Site Review Tool for Providers.
Unlicensed AFL reviews are health and safety reviews of unlicensed community-based private homes. These reviews occur annually for N.C. Innovations participants and every two years for non-Medicaid members.
To add or change AFL home information, click below.
This annual review ensures compliance with the requirements of the Substance Abuse Prevention and Treatment Block Grant and Block Grants for Community Mental Health Services. Block grant monitoring consists of a review of multiple programs. It also includes record reviews for specific service requirements.
Vaya providers are required to participate in the NC-TOPPS system. NC-TOPPS interviews collect vital information about the people served by North Carolina’s mental health and substance use services system. Vaya network providers are required to maintain a 90 percent compliance rating on submission of NC-TOPPS interviews as outlined on the NC-TOPPS website.
Complete Vaya’s NC-TOPPS Online Training below to learn more.