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.
| 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 Practioner (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) |
| Replacement Claims Guidelines Professional Claims |
| 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 |
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.).
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Provider Support Service Line
Available Mon. - Sat., 7 a.m. - 6 p.m. Open Monday through Saturday 7 a m to 6 p m
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Suite 218
Asheville, NC 28806
