Vaya Health’s Utilization Management team is responsible for reviewing service authorization requests and providing clinical oversight of the services covered in our benefit plans. Utilization Managers review progress towards members’ recovery and rehabilitation goals on an individual basis and ensure that services are authorized that match each member’s needs. Authorization decisions are based on medical necessity, member need, service requirements, endorsed best clinical practices, EPSDT requirements (for Medicaid beneficiaries under age 21), and funding availability (for non-Medicaid services). Vaya Health does not offer any type of incentive for utilization managers or other utilization review staff to deny, limit, or discontinue medically necessary services to any member.
Please refer to the Authorizations page for more information about the prior and concurrent authorization process. If a Vaya Health Utilization Manager is unable to authorize a requested service, the Peer Review process is followed. When appropriate, Utilization Managers may refer members for Vaya Health’s Care Coordination services or consult with staff physicians and pharmacists to ensure that members are getting quality care in the best setting possible.
Vaya adopts clinical guidelines that are intended to guide our providers on how to follow national and community standards of practice. Our purpose is to assure easy access, appropriate, high quality services for members, and the elimination of ineffective and poor outcome services and practices. Providers are expected to maintain and/or advance the quality of services through the demonstration of practice consistent with pertinent Clinical Guidelines and Best Practices.
For more information about our benefit plans, Clinical Practice Guidelines, Clinical Coverage policies, service definitions and other coverage requirements, please refer to the Coverage Information page.