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

Alphabetical list of documents and forms

837i 5010 Data Clarification Manual 
837p 5010 Data Clarification Manual
837p and 837i Steps For Testing and Approval 
ASAM Worksheet for Adolescents 
ASAM Worksheet for Adults 
Authorization and Release for Background Checks 
Authorization for Release of Information 
CANS Assessment 0-4 Years Rating Sheet
NCDHHS Children with Complex Needs Settlement Referral
Claims Adjudication Codes and Actions 
Clinical Practice Guidelines and Leveling Tools
Community Guide (b)(3) Waiver Service 
Criterion 5 Form 
CSV RA Conversion Template 
Diversion Law Exception Worksheet 
Downloading And Importing AlphaMCS Detail Files
EDI Enrollment Form
EFT Authorization Agreement for Automatic Deposit 
Enrollment Initiation Form: Licensed Practitioner (LP)
EPSDT Non-Covered Services Request Form
Follow-Up After Emergency Department Visit for Mental Health
Geriatric Team Referral Form 
Good Faith Contracting Policy
High-Volume Claim Inquiry Form 
I/DD Bed Board – Residential Vacancy Reporting
Independent Assessment for Personal Care Services (PCS) (Start date: 30 days prior to Tailored Plan Launch)
Initial Level of Care Eligibility Determination: 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
Inpatient Concurrent Review Form 
IRIS Incident Report Form 
Job Aid: Provider Portal Security Access Administrator
Local Barriers Committee Request Form
Long Term Community Supports (LTCS) in lieu of Service Definition 
Medicaid Covered Diagnoses
Medicaid Covered Diagnoses: Special Populations
Member-Specific Out-of-Network Agreement Request
NC Medicaid Provider Satisfaction Survey (2021)
Network Adequacy and Accessibility Analysis (2021)
Network Provider Participation Agreement
Network Provider Systems Access Administrator Designation
Non-Medicaid-Funded ACT Policy 
Non-Medicaid-Funded Critical Time Intervention 
Non-Medicaid-Funded Developmental Therapy Service 
Non-Medicaid-Funded Facility-Based Crisis Child 
Non-Medicaid-Funded Inpatient Behavioral Health Services 
Non-Medicaid-Funded IPS-SE For AMH-ASA
Non-Medicaid-Funded MH/DD/SU Service Definitions 
Non-Medicaid-Funded MHSU Enhanced Service Definitions 
Non-Medicaid-Funded Transition Management Services 
Non-Medicaid Residential Services Referral Profile 
Non-UCR Invoice Template
Out-of-Network Enrollment Request Form
PCP Member Transfer Form Upload
PCS Assessment Request Form
Physician Consultation (b)(3) Waiver Service
Program Integrity Incident Reporting Backup Staffing Form 
Provider-Based TCM Innovations Waiver Emergency Slot Form
Provider Contract Request Form
Provider Operations Manual
Provider Self-Audit Overpayment Workbook 
Provider Self-Audit Protocol For Paid Claims Audits
Psychological Testing Authorization Request Form 
Quarterly Provider Level I Incident Report
Rate Request – Enhanced Rate Budget Worksheet
Rate Request – Existing Service Rate Request
Rate Request – Member- and/or Recipient-Specific Rate Request
Regional Referral Form (ADATC)
Regional Referral Form (State Psychiatric Hospital)
Request for Claims Denial Appeal Review (Level 1)
Short-Range Goal Template For N.C. Innovations Providers 
Supported Employment (b)(3) Waiver Service 
TBI Funding Request Form
TCL Community Monthly Update Form Link
TCM External Clinical Consultation Request
Universal Child and Adolescent Residential Placement Referral Form En Español
Use of Antipsychotic Medications and Monotherapy (1/24/2020)
Vaya Health-Tested Clearinghouses 

External links

Related to payment and billing

» ICD-10 Code Search

» NCTracks Website

N.C. DHHS/DHB/DMH Resources

» N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services

» NC Medicaid

» N.C. DHHS Person-Centered Planning forms

» Medicaid Clinical Coverage Policies

» N.C. Division of Health Benefits Clinical Coverage Policy No: 8P

» N.C. Division of Mental Health, Developmental Disability and Substance Use Services (DMH/DD/SUS) Service Definitions

» NC-SNAP (NC Support Needs Assessment Profile)

Network participation

» Letter of Support Request

» Provider Nomination Form

» Provider Operations Manual

» RaDSE DocuSign® Form

Performance and quality

» AFL Update Form

» Fraud Prevention Toolkit

» Incident Response Improvement System

» NC-TOPPS website

» N.C. Department of Health and Human Services (DHHS)

» N.C. DHHS Agency Monitoring Tools for Providers

» N.C. DHHS Audit Information

» N.C. DHHS Consumer Perceptions of Care reports

» N.C. DHHS Monitoring Changes FAQ

» N.C. DHHS Home and Community Based Settings (HCBS) Self Assessment (Paper Version)

» N.C. DHHS New Unlicensed Site Review Tool for Providers

» N.C. DHHS Review Tool for LIPs/ Group Practices and Agencies Billing Outpatient Services Only

» N.C. DHHS Unlicensed AFL Review Tool for Provider

Need Help?

For information or technical assistance, call Vaya Health’s Provider Support Service Line at
1-866-990-9712
(Monday-Saturday, 7 a.m.- 6 p.m.).