Authorizations for Services

Service Authorization Process and Request Form

Service Authorization Requests should be made in our electronic Managed Care System, AlphaMCS.

If you are having difficulty with our electronic Managed Care System, please use the link below to download a copy of the Service Authorization Request form in Microsoft Word format. The document should be completed, scanned and e-faxed to UM@vayahealth.com.

Service Authorization Request – Electronic Form

Questions? 
Contact care management staff at 828-225-2785  ext. 1513

 

Prior Authorization Forms for Inpatient and Substance Use ADATC Residential Care

For Vaya Health members who are admitted to an inpatient psychiatric unit, providers should complete and include the following document in the request for authorization:

Initial authorization:  Regional Assessment and Referral Form (RARF)

Continued authorization: Inpatient Concurrent Review Form   

Criterion 5 Form

For Vaya Health members who are referred to the Alcohol and Drug Abuse Treatment Center (ADATC) for detoxification services, the referring provider should contact ADATC at 828-257-6400 to begin this process.  If the member is approved for admission by ADATC, the provider should complete the following document to send to Customer Services department at 1-877-917-9887.

Please review the Processes for referral to Alcohol and Drug Abuse Treatment Center (ADATC) Detox and State Hospital Facilities.

The Regional Referral Form

For Vaya Health members who are referred to the Alcohol and Drug Abuse Treatment Center (ADATC) for rehabilitation services, the referring provider should complete the following document and submit consents to release information and other clinical documentation to our ADATC fax line 1-877-651-9968 to begin this process:

The Regional Referral Form

For Vaya Health members who are referred to Broughton State Hospital (BSH), the referring provider should complete the following document and fax the assessment and RRF to Customer Services department at 1-877-917-9887 to begin this process:

The Regional Referral Form

For Vaya Health members who are diagnosed with (or suspected diagnosis of) Intellectual Disability and co-occurring mental illness and are referred to BSH, the referring provider should also complete the following form to submit along with documentation as described above:

Child and Adolescent Universal Residential Placement Application

For referring agencies/individuals to streamline discharge planning and eliminate the time and redundancy associated with multiple agency-specific applications. Use of this form does not, and should not be construed to, guarantee authorization of residential or other treatment by Vaya Health, and responsibility for appropriate discharge from inpatient facilities remains with the discharging provider.

Worksheet for Requesting Exceptions to the Diversion Law (SB859) for the 4 exceptions.

For requests to transfer a patient from another inpatient psychiatric unit to BSH, the facility should contact us during business hours at 1- 866-990-9712, option 5 to discuss the requested transfer.

EPSDT

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is the federal law that says Medicaid must provide all medically necessary health care services to Medicaid-eligible children. Even if a service is not covered under the NC Medicaid State Plan, it can be covered for recipients under 21 years of age if the service is listed at 1905(a) of the Social Security Act and if all EPSDT criteria are met.

Services must be ordered by the child’s physician or another licensed clinician.  The services must meet all of the three following conditions:

  1. The service must be medically necessary to correct or ameliorate a defect, physical or mental illness or a condition that is identified through a screening examination.
  2. The service must be listed in section 1905(a) of the Social Security Act.
  3. The service cannot be experimental/investigational, unsafe or considered ineffective.

For more information about EPSDT, please call Vaya Health Care Management at 1-866-990-9712, Option 5 or visit the DHHS website at: https://www2.ncdhhs.gov/dma/epsdt/

EPSDT Request Form


Medicaid Authorization Guidelines

State Authorization Guidelines

 


Level of Care Tools

Child Mental Health (ages 0-4) – CANS Assessment for Children (0-4 Years)

Child Mental Health (ages 6-17) – CALOCUS Scoresheet

Adult Mental Health – LOCUS Scoresheet

Child/Adolescent Substance Use – ASAM Worksheet for Adolescents

Adult Substance Use – ASAM Worksheet for Adults 

Call 1-800-849-6127 toll free 24/7 to access mental health, substance use and intellectual and/or developmental disability services. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.