Vaya Health
Service Authorization Request (Paper SAR) Submit the completed, signed form to Vaya by mail, fax or email:
BY MAIL:
Vaya Health Utilization Management 200 Ridgefield Court, Suite 218 Asheville, NC 28806
BY FAX:
Vaya Health Utilization Management 828-348-4141
BY EMAIL:
NonStandardAuths@ vayahealth.com
* = Required field. If a required field is incomplete, UM will be unable to process the request. Submission date:*
______________________
Individual submitting request (with credentials, when applicable):* __________________________________________
Please provide contact information in the event the reviewer must contact you for additional information: Contact name:*
_______________________________________________________________________
Type of service request:
□ MH □ SUD □ IDD
Telephone number:* _____________________________
□ Initial request □ Concurrent request
DEMOGRAPHICS
PROVIDER INFORMATION
Member AlphaMCS ID:* ________________________________________________
Provider name:* _______________________________________________________
________________________________________________
Medicaid provider number:* ____________________________________________
Member name:*
□ Male □ Female DOB:* _______________________ SSN #:* _______________________
Age: ___________
Medicaid ID #:* _______________________
City/state:* ____________________ Telephone #:*
NPI number:*
_______________________________________________________
Service address:* _______________________________________________________
_______________________
LEGAL GUARDIAN INFORMATION (if applicable): Legal guardian name: ___________________________________________________ Relation:
□ Parent □ DSS □ Other
Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Utilization Management | Rev. 12.01.2022 Version 3.1
DSM 5 diagnosis(es): Please provide diagnosis name in addition to code. * ________________; ________________; ________________; ________________; ________________; ________________; ________________; ________________;
Substance use information (if applicable): Substance used
Age of 1st use
Route (oral, IV, etc.)
Level of Care Assessments
Frequency
Date last used
Medical
LOCUS score (Adult MH/SU):
___________________
Attending physician:
______________________________________________________________
CALOCUS score (Child MH/SU):
___________________
Allergies:
______________________________________________________________
ASAM (SU):
___________________
SNAP (IDD):
___________________
SIS score (IDD):
___________________
CANS score (Child MH/SU under age 6):
___________________
Date of above assessment(s):
___________________
Service code and name*
Medicaid or state funds?*
Service site*
Comprehensive list of current medications: (please attach separate list if more space is needed) Name
Units*
Frequency*
Choose one:
Choose one:
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Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Dose
Total units*
Frequency
Start date*
End date*
Utilization Management | Rev. 12.01.2022 Version 3.1
Reason for admission, continued service or other comments/justification:*
List of supporting documents attached to this request presented for review:*
FOR VAYA HEALTH STAFF COMPLETION ONLY: Person receiving request
Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Request receipt date
SAR # assigned
Request logged? (Y/N)
Utilization Management | Rev. 12.01.2022 Version 3.1