Vaya Health’s Care Management team is responsible for reviewing service authorization requests and providing clinical oversight of the services covered in our benefit plans. Care Managers review progress towards members’ recovery and rehabilitation goals on an individual basis and ensure that services are authorized that match each member’s needs. Authorization decisions are based on medical necessity, member need, service requirements, endorsed best clinical practices, EPSDT requirements (for Medicaid beneficiaries under age 21), and funding availability (for non-Medicaid services). Vaya Health does not offer any type of incentive for care managers or other utilization review staff to deny, limit, or discontinue medically necessary services to any member.
Please refer to the Authorizations page for more information about the prior and concurrent authorization process. If a Vaya Health Care Manager is unable to authorize a requested service, the Peer Review process is followed. When appropriate, Care Managers may refer members for Vaya Health’s Care Coordination services or consult with staff physicians and pharmacists to ensure that members are getting quality care in the best setting possible.
For more information about our benefit plans, Clinical Practice Guidelines, Clinical Coverage policies, service definitions and other coverage requirements, please refer to the Coverage Information page.