When a Vaya Health utilization management (UM) clinician is unable to approve a request based on medical necessity or Early Periodic Screening, Diagnostic and Treatment (EPSDT), the request will be referred to a licensed doctoral psychologist or physician for peer review.
For N.C. Innovations services, the member’s assigned care coordinator submits the Service Authorization Request (SAR), current person-centered plan of care, assessments and any other documentation that you or the member, the legally responsible person or the family requests be submitted for review. For all other services, you are responsible for submitting a SAR and all supporting documentation for the request.
UM reviews the SAR and all information submitted with it when making medical necessity determinations. Vaya may contact you to obtain additional information.
When conducting peer-to-peer reviews, peer reviewers will make at least one attempt to contact the appropriate provider representative. However, because of the tight turnaround time requirements for authorization decisions, the window to conduct peer-to-peer discussions is usually short.
If the peer reviewer is unable to reach you or does not think that a peer-to-peer conversation is necessary, Vaya will make a decision based on the information submitted with the SAR. If Vaya issues a medical necessity denial without having conducted a peer-to-peer discussion, you may request one within three business days of the denial notice.
This discussion is not an appeal of the adverse benefit determination. Rather, it is an opportunity to discuss the decision and the reasons Vaya could not approve the request. However, if based on the peer-to-peer discussion, the peer reviewer determines a different decision should have been made, Vaya may change the initial decision.