Authorizations for Services
Service Authorization Request Form
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.
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
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 Service s department at 1-877-917-9887:
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:
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:
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:
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.
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:
- 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.
- The service must be listed in section 1905(a) of the Social Security Act.
- 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/
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