Vaya Health
Member- and/or Recipient-Specific Rate Request Please complete all fields as applicable. Submit the completed request form and any supporting documentation by secure email (via Zixmail or other encrypted service) to provider.info@vayahealth.com. Incomplete request forms may be returned to the submitter for additional information.
PART A: GENERAL INFORMATION Member/ Recipient name:
Medical record number:
Date of birth:
Date submitted:
Provider legal name and full primary mailing address:
Provider site(s) address(es) (where services are authorized):
NAME AND CONTACT INFO FOR PERSON SUBMITTING REQUEST (RATE DECISION NOTICE WILL BE SENT TO THIS PERSON):
The person named here is responsible for submitting a complete request and for answering questions related to this request. Name and Title:
_____________________________________________________________
Email: _______________________________________________________________________ Complete mailing address: _____________________________________________________________________________ Phone number:
_____________________________________________________________
Service name:
Procedure code:
Service name:
Procedure code:
Service name:
Procedure code:
Benefit plan:
Medicaid
State funds
Vaya Health | Member-Specific Rate Request Copyright © 2021 Vaya Health. All rights reserved.
Other: ________________________________________
Finance | Rev. 11.29.2021 Version 2.0
PART B: MEMBER/ RECIPIENT RATE REQUEST (Attach a separate Part B for each service) Service name from Part A:
Proposed rate: $ _____________
Unit of service (check one):
Existing rate:
15 min.
Hourly
Daily
$ _____________
Other
If other, please provide the time increment: ________________________ Estimated units utilized per member/ recipient per year if request approved: Differentiate by fund source, if applicable.
Total estimate of annual budget for service: Differentiate by fund source, if applicable. Include Cost Summary for NC Innovations participants.
Summary of justification: Provide a narrative of your findings in your cost model, including, but not limited to: (1) The cost structure of the standard rate and detail of the increased cost that supports the higher rate and cost:
(2) The additional cost you will incur that is not included in the current rate:
DO NOT include medical necessity information. Medical necessity is determined by qualified clinicians within the Vaya Health Utilization Management team, independent of any rate decision. Cost modeling and budget: This request must include complete and sufficient financial information to support the request via the Budget Worksheet. Did you include cost modeling and the Budget Worksheet?
Vaya Health | Member-Specific Rate Request Copyright © 2021 Vaya Health. All rights reserved.
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Finance | Rev. 11.29.2021 Version 2.0