Vaya Health
Service Authorization Request (Paper SAR) Submit the completed, signed form to Vaya Health 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, Vaya cannot 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:*
Phone:*
☐ Intellectual/developmental disability (I/DD) Type of service request: ☐ Mental health (MH) ☐ Substance use disorder (SUD) ☐ Traumatic brain injury (TBI) ☐ Initial request ☐ Concurrent request Demographics Member/recipient name:* Date of Birth:* SSN #:* City/State:*
AlphaMCS ID:* Age:
☐ Male ☐ Female
☐ Non-binary
Medicaid ID #: Phone #:
Legal Guardian Information (if applicable): Legal guardian name:
Relation: ☐ Parent ☐ DSS ☐ Other
Provider Information Provider name:* Medicaid provider number:*
NPI number:*
Service address:*
Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Utilization Management | Rev. 12.28.2022 Version 3.0
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.)
Frequency Date last used
Level of Care Assessments LOCUS score (Adult MH/SUD)
ASAM (SUD)
CALOCUS score (Child MH/SUD)
SNAP (I/DD)
CANS score (Child MH/SUD under age 6)
SIS score (I/DD)
Date of above assessment(s): Medical Attending physician: Allergies: Comprehensive list of current medications: (please attach separate list if more space is needed) Name
Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Dose
Frequency
Utilization Management | Rev. 12.28.2022 Version 3.0
Service code and name*
Service site*
Medicaid or State funds?*
Units*
Total units*
Frequency*
Start date*
End date*
Reason for admission/continued service or other comments/justification:*
List of supporting documents attached to this request presented for review:*
For Vaya Staff Completion Only: Staff receiving request: Request receipt date: SAR # assigned:
Vaya Health | Service Authorization Request Copyright © 2022 Vaya Health. All rights reserved.
Request logged? ☐ Yes ☐ No
Utilization Management | Rev. 12.28.2022 Version 3.0