Utilization Management

Federal Medicaid regulations require us to perform utilization reviews and service management. These processes help us keep track of the type and amount of services provided, as well as how often they are used. Our Utilization Management team is staffed by experienced clinicians who review requests for services. Their priority is always to ensure you get the right care, in the right amount and at the right time.

We do not engage in practices that would provide incentives to care management staff or contractors should they deny, reduce, terminate, suspend, limit or discontinue medically necessary services to any member. Our decision-making is based only on member eligibility and whether the requested service is appropriate using established medical necessity, as well as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) criteria, clinical practice guidelines, waiver limits and service definition requirements. We do not offer rewards to providers for denying services. There are no financial incentives for our care management staff that would discourage approval of services.

Individuals receiving services must meet medical necessity criteria for the amount and duration of the requested services. Medicaid beneficiaries enrolled in Vaya Health’s Health Plan are entitled to medically necessary services to address their specific condition. Individuals without Medicaid who meet medical necessity criteria will receive services to the extent they are eligible and resources are available.

Call 1-800-849-6127 toll free 24/7 to access mental health, substance use and intellectual and/or developmental disability services. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.