Tailored Plan Clinical Coverage Policies
June 01, 2022 Authorization Guidelines Vaya Health uses applicable federal and state laws, rules and regulations, clinical coverage policies (CCPs), authorization guidelines, and other formal guidance promulgated by NCDHHS, the Centers for Medicare & Medicaid Services and other applicable oversight bodies to make decisions about service authorization requests. You and your staff must be familiar with applicable CCPs and authorization guidelines as they apply to the services you provide. For services that require authorization, you may not seek payment for amounts or units that exceed those approved for authorization by Vaya. For Medicaid and NC Health Choice services, Vaya uses NC Medicaid Clinical Coverage Policies to make medical necessity decisions. Vaya also offers Medicaid and NC Health Choice “in Lieu of” services and additional services under the 1915 (i) waiver as approved by NCDHHS. These service definitions are available on our website here. For State-Funded behavioral health and intellectual/developmental disability services, Vaya uses NC Division of MHDDSAS Service Definitions to make medical necessity decisions. Vaya also offers “Alternative Services” through state funds as approved by NCDHHS. These service definitions are available on our website here.
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