The Contract Performance Unit of Vaya Health assures that the provision of service to our members meets the highest standard of quality, while also working collaboratively with our Provider Network.
MCOs are required by statute (NC GS § 122C-111) to monitor public mental health, intellectual/developmental disability and substance abuse services. Types of monitoring conducted by the Contract Performance Unit of Vaya Health are listed below. Any provider offering services to Vaya Health members is subject to monitoring.
Types of Monitoring:
Vaya Health conducts multiple types of provider monitoring activities. For your reference, tools for specific reviews are listed below.
For more information, please click on the titles to expand or close the boxes below.
Targeted and time-sensitive investigations that assess quality of care, health and safety issues, and service definition compliance.
A review that is conducted as soon as possible to assess the health and safety of our members.
Effective July 3, 2017 Attention
Provider agencies that are nationally accredited and are licensed facilities monitored annually by DHSR will be reviewed at a minimum of every two years, using the post-payment review tool ONLY. In accordance with LME-MCO Communication Bulletin #J254, these agencies are no longer monitored using the routine monitoring tool as of July 3, 2017. Provider agencies nationally accredited two years or more are required to deliver a copy of the official notification (e.g. letter, memorandum, certificate, etc.) from the agency’s accrediting body within 30 days of receipt. Provider agencies that receive only a provisional or one-year accreditation must submit all findings of the accrediting body to Vaya Health within 30 days of receipt. Upon review of the findings, Vaya Health may decide to conduct a targeted monitoring or post payment review. Failure to maintain any required national accreditation may result in an adverse action, up to and including revocation of credentialing and termination of contract.
For questions related to these agency monitoring changes view the DHHS FAQ here.
Update Effective July 1, 2018 Attention
Changes to the DHHS LIP/Agency Practice Provider Monitoring Review Process: In accordance with LME-MCO Communication Bulletin #J292, LIPs/ Group Practices and Agencies Billing Outpatient Services Only (BH) are no longer monitored using the routine monitoring tool as of July 1, 2018.
LIP Review Tool
- The DHHS LIP Review Tool (in the workbook dated May 3, 2018) will no longer be utilized by the LME-MCOs to monitor practitioners/practices on a two-year cycle. The tool will be archived.
- Any outstanding Plan of Correction (POC), prior to the sunset of the DHHS LIP Review Tool, will need to be finalized with the appropriate LME-MCO(s).
Post Payment Review Tool
- The DHHS Post-Payment Review Tool for Licensed Independent Practitioners has been renamed, DHHS Review Tool for LIPs/Group Practices and Agencies Billing Outpatient Services Only (BH) to more appropriately reflect how and by whom the tool is utilized (e.g., Individual Practitioners, Group Practices and Agencies Billing Outpatient Services Only (Behavioral Health).
- Revisions to the Guidelines include: removal of language that is not specific to either practitioners or practices, (e.g., references to Innovations, updated citations, and minor clarifications that will improve the overall process).
Other important information includes:
- Reviews will continue on a two-year cycle.
- There will be no change in current practice for the following tool: DHHS New Unlicensed Site Review Tool for Providers.
The Block Grant Review is conducted annually to ensure compliance with the requirements of 45 CFR Part 96, Subpart I, the Substance Abuse Prevention and Treatment Block Grant (SAPTBG) and of 42 USC Part B, Subpart I, Block Grants for Community Mental Health Services (CMHBG). Block Grant monitoring consists of a review of multiple programs. It also includes record reviews for specific service requirements.
Vaya Health providers are required to participate in the NC-TOPPS system as outlined by the NC-TOPPS guidelines. NC-TOPPS interviews collect vital information about the people served by the North Carolina mental health and substance use system. Vaya Health providers are expected to maintain a 90% compliance rating on submission of NC-TOPPS interviews as outlined on the NC-TOPPS Website.