NOVEMBER 30, 2021 | COMMUNICATION BULLETIN 2021-22 ISSUE 29 IN THIS ISSUE: Vaya Health Authorization Guidelines Updates | Standard Rate Schedules Updates | Rate Floor for Crisis Services and COVID-19/PHE Rate Supplements | Vaya Enhanced Rate Setting Process | Appendix K Reporting Process Change | Joint DMH/DHB Monthly Provider Call | NCDHHS Secretary Cohen to Step Down, Kinsley Tapped to Lead Department
Vaya Health Authorization Guidelines Updates To access updated authorization guidelines effective Jan. 1, 2022 for Vaya’s 31-county region, visit our Authorizations Guidelines webpage. Please note that this page includes both current Vaya authorization guidelines and a section containing the guidelines that will go into effect upon consolidation with Cardinal Innovations Healthcare (Cardinal) on Jan. 1, 2022. To help providers navigate changes during the consolidation period, Cardinal had eliminated prior authorization requirements for some services. Please review the guidelines at the link above to determine which services will require prior authorization beginning on Jan. 1, 2022. Prior to this date, Vaya will issue a crosswalk of service codes to clarify any changes that providers must be aware of when submitting service authorization requests (SARs).
In-Lieu-Of and Alternative Services In-lieu-of services and State-funded alternative services that were offered solely in the nine legacy Cardinal counties are not included in Vaya’s rate schedules and authorization guidelines at this time. Vaya will add these services upon final approval from NCDHHS for the consolidated Vaya region, with approval expected prior to Jan. 1, 2022. If approval is delayed, Vaya will be unable to process these service requests and will work with providers to develop appropriate service plans for affected members. EPSDT Guidelines If you want to request services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, please visit Vaya’s EPSDT webpage for further instruction. SAR Processing Providers serving members in the nine legacy Cardinal counties should begin submitting SARs to Vaya on Jan. 3, 2022. If submitted on or before Jan. 16, 2022, Vaya will process SARs for retroactive dates of service with start dates back to Jan. 1, 2022. To help ensure timely SAR processing, please review Vaya’s Oct. 8, 2020 Provider Communication Bulletin for information about submitting complete requests.
How Authorizations will Transfer to Vaya Vaya will honor any authorizations issued by Cardinal Innovations for members in the nine legacy Cardinal counties. Providers must submit claims for dates of service prior to Jan. 1, 2022 directly to
Cardinal. Claims for dates of service on or after this date must be submitted to Vaya. For inpatient psychiatric care providers serving members from legacy Cardinal counties: Continue to submit requests through GuidingCare for dates of service that begin in December 2021. For requests for dates of service that begin on Dec. 27, 2021, please request through Jan. 3, 2022. Cardinal requests that, beginning at noon on Dec. 30, 2021, providers withhold request submissions until Jan. 3, 2022, when a retroactive request may be submitted in GuidingCare. If there is a specific reason why a hospital cannot hold requests during the Dec. 30-Jan. 3 period, providers may still submit requests. However, Cardinal staff resources will be limited during this time, and they request that providers hold these requests if possible. Beginning Jan. 3, 2022, all new requests for inpatient care that require prior authorization should be submitted in Vaya’s AlphaMCS system. Note that Vaya’s authorization guidelines for these services are different than Cardinal’s as it relates to pass-through requirements. Vaya regularly requires inpatient providers to submit an admission notification SAR and any required documentation within 48 hours of admission; however, providers transitioning from Cardinal may submit inpatient care requests as soon as possible from Jan. 3-16, 2022. For providers of non-inpatient services in the legacy Cardinal counties: For all authorizations that start in December 2021 and extend past Jan. 1, 2022, Cardinal requests that providers submit requests by Dec. 15, 2021, if possible. Authorizations submitted after Dec. 15, 2021 will be processed but may not be transferred to Vaya immediately on Jan. 1, 2022. Additional notes: All authorizations for members with eligibility from the nine Cardinal legacy counties that extend beyond Jan. 1, 2022 will be loaded to the AlphaMCS system. The only exception is for services that do not require prior (or concurrent) authorization and therefore do not require a notification SAR. Please refer to the authorization guidelines to determine which services require prior or concurrent authorization. For more information, contact Vaya’s Utilization Management team at UM@vayahealth.com or 1-800893-6246, ext. 1513.
Standard Rate Schedules Updates Vaya has published updated standard rate schedules that take effect on Jan. 1, 2022, on our Rate and Checkwrite Schedules webpage. Please note that the current rate schedules also remain available for viewing. The rate schedules are organized into three documents by benefit plan: Medicaid(b), Medicaid (c), and Non-Medicaid/State-funded Services. The rate schedules include the standard base rates for services and do not include any COVID-19 or public health emergency (PHE) rate enhancements. Procedure codes eligible for COVID-19/PHE rate supplements are identified on the standard rate schedules. For more information, please read the memo linked below. The rate schedules also do not include any rates that are provider-specific, provider-site specific, or member-specific. For the sake of ease, certain modifiers – including AH, AJ, CR, GT, KX, and XU – are not listed separately in the rate schedules. The rates for procedure codes with these modifiers will be the same as the standard code base rate. For additional information on standard rate schedules, please email provider.info@vayahealth.com.
Rate Floor for Crisis Services and COVID-19/PHE Rate Supplements Please review the linked memo to review rate schedule changes for crisis services and current and future COVID-19/PHE rate supplements.
Vaya Enhanced Rate Setting Process Vaya maintains an established process for providers to request enhanced rates for services due to circumstances unique to their service delivery or to the member(s) being served.
Orientation to Request Forms Updated rate request forms and the Vaya Enhanced Rate Budget Worksheet are posted on the Vaya Forms webpage. Please select the form applicable to your request: Member-Specific Rate Request: Applies to a single member for a contracted service Existing Service Rate Request: Used when seeking a provider-specific or provider site-specific rate for a contracted service Providers must complete and submit the Vaya Enhanced Rate Budget Worksheet along with the applicable rate request form listed above. Please submit all documents via secure email to provider.info@vayahealth.com.
Request and Decision-Making Process Vaya’s Provider Network Operations (PNO) department will perform an initial review of the request to ensure correct forms were submitted and contain all required information. Vaya will return all incomplete requests to the provider for completion. Vaya’ Rate Setting Committee meets twice a month and reviews requests in the order in which they are received. Providers will receive a written notice of approval or denial via email after the committee reaches a decision.
Decision Criteria The Rate Setting Committee reviews and evaluates completed requests using a consistent set of criteria that include: Whether the service fills a special need or is available from another network provider Whether the request provides a breakdown of staffing and/or other expenses to justify the rate increase Whether direct and indirect expenses and administrative overhead are consistent with expenses of other providers with similar sites and services The provider’s willingness to maintain continuity of care while the enhanced rate is reviewed The overall budgetary impact of the request Whether funds are available to support the rate increase There is no entitlement to an enhanced rate for a member or for a provider. Rate Setting Committee decisions are final, and there are no appeal rights for a member or a provider based on denied enhanced rate requests. Standard grievance rights may apply. For additional information about the rate request forms or the request review process, please email provider.info@vayahealth.com.
Appendix K Reporting Process Change Effective Jan. 1, 2022, Vaya providers of NC Innovations Waiver services will follow a new process for reporting new COVID-19 Appendix K Flexibilities. To report the use of a new flexibility or an extension of a previously reported one, providers will complete the Appendix K Reporting Form available on Vaya's website. This will eliminate the need to fax or scan these forms. We will notify providers when the form is available for use. Providers who have previously submitted an Appendix K Reporting Form to Cardinal Innovations or Vaya will not need to resubmit information unless new flexibilities are requested. Please direct questions or concerns to provider.info@vayahealth.com.
Joint DMH/DHB Monthly Provider Call Thursday, Dec. 2, 2021, 3 p.m. This week’s Joint DMH/DHB Monthly Provider Call will include a presentation and discussion of the (i) option. Panelists will present policy updates from Division of MHDDSAS and NC Medicaid representatives, followed by an open Q&A session. A representative from the NC Division of Health Service Regulation (DHSR) will also be present to answer questions. Register online: https://attendee.gotowebinar.com/register/1546111679395207948 After registering, you will receive a confirmation email containing information about joining the webinar.
NCDHHS Secretary Cohen to Step Down, Kinsley Tapped to Lead Department Gov. Roy Cooper announced Tuesday that NCDHHS Secretary Mandy Cohen, MD, will step down from the agency after five years of service to the state. The governor has appointed Kody Kinsley, current NCDHHS Chief Deputy Secretary for Health and lead for COVID-19 operations, to succeed Cohen beginning Jan. 1, 2022. Read more.
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