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Forms

Looking for a form or document? You can view a list of forms and documents by clicking below or using the search in the upper right of this site. 

Please refer to the following forms, tools, and other resources to help you perform your functions as a network provider. For additional assistance, call 1-866-990-9712 or email provider.info@vayahealth.com. 

Network Participation

» Authorization and Release for Background Checks

» Enrollment Initiation Form: Licensed Practitioner (LP)

» Letter of Support Request

» Member-Specific Out-of-Network Agreement Request

» Network Provider Systems Access Administrator Designation

» Out-of-Network Enrollment Request Form

» Provider Contract Request Form

Claims and Billing

» 837i 5010 Data Clarification Manual 

» 837p 5010 Data Clarification Manual

» 837p and 837i Steps For Testing and Approval 

» Claims Adjudication Codes and Actions 

» CSV RA Conversion Template

» EDI Enrollment Form

» EFT Authorization Agreement for Automatic Deposit 

» High-Volume Claim Inquiry Form 

» ICD-10 Code Search

» Non-UCR Invoice Template

» Provider Hardship Advanced Request Form

» Provider Self-Audit Overpayment Workbook 

» Provider Self-Audit Protocol For Paid Claims Audits

» Rate Request – Enhanced Rate Budget Worksheet

» Rate Request – Existing Service Rate Request

» Rate Request – Member- and/or Recipient-Specific Rate Request

» Request for Claims Denial Appeal Review (Level 1)

» Vaya Health-Tested Clearinghouses 

Authorizations and Referrals

» NCDHHS Children with Complex Needs Settlement Referral

» Criterion 5 Form 

» Diversion Law Exception Worksheet 

» EPSDT Non-Covered Services Request Form

» Geriatric Team Referral Form 

» Inpatient Concurrent Review Form 

» Medicaid Covered Diagnoses

» Medicaid Covered Diagnoses: Special Populations

» Non-Medicaid Residential Services Referral Profile 

» PCS Assessment Request Form

» Psychological Testing Authorization Request Form 

» Regional Referral Form (ADATC)

» Regional Referral Form (State Psychiatric Hospital)

» TBI Funding Request Form

» TCM External Clinical Consultation Request

» Universal Child and Adolescent Residential Placement Referral Form | En Español

Clinical Tools

» ASAM Worksheet for Adolescents

» ASAM Worksheet for Adults

» CANS Assessment 0-4 Years Rating Sheet

» Clinical Practice Guidelines and Shared Decision-Making Tools

» Initial Level of Care Eligibility Determination: NC Innovations Waiver

Incident Reporting

» Backup Staffing Form

» IRIS Incident Report Form

» Quarterly Provider Level I Incident Report

Miscellaneous Forms

» AFL Update Form

» Authorization for Release of Information

» I/DD Bed Board – Residential Vacancy Reporting

» Local Barriers Committee Request Form

» PCP Member Transfer Form Upload

» TCL Community Inclusion Monthly Update Form

NC Innovations Waiver

» Innovations Freedom of Choice Acknowledgement

» Innovations Out-Of-State Travel Form Out-of-State Travel Common Questions and Answers

» Innovations Waiver Health Plan Transfer Form

» Innovations Waiver Participant Responsibilities

» NC Innovations Provider Quarterly Self Review of Member Record

» Self-Review of Innovations Member Record Job Aid

» Provider-Based TCM Innovations Waiver Emergency Slot Form

» RaDSE DocuSign® Form

» Short-Range Goal Template For N.C. Innovations Providers 

NCDHHS Forms

» NC DHHS Person-Centered Planning forms

» NC-SNAP (NC Support Needs Assessment Profile)

» NC DHHS Agency Monitoring Tools for Providers

» NC DHHS Home and Community Based Settings (HCBS) Self Assessment (Paper Version)

» NC DHHS Provider Review Database

» NC DHHS Review Tools for LIPs

» NC DHHS Unlicensed AFL Review Tool for Providers

» NC DHHS Unlicensed Site Review Tool for Providers