Appeals & Grievances
Filing an Appeal
We want you to understand your right to file requests for reconsideration and appeals. Please remember it is important to follow exactly all procedures that come to you in notices and letters sent to you by Vaya Health, including any timelines or deadlines in the letter.
Medicaid beneficiaries have a constitutional right to due process before a Medicaid benefit is taken away.
Due process means you are entitled to a written notice and an opportunity for a hearing. Our Medicaid appeals system is based on this fundamental right to due process.
What are the types of issues that can be appealed by a Medicaid beneficiary?
You can appeal any “adverse benefit determination” issued by Vaya Health. An adverse benefit determination occurs whenever Vaya Health:
- Denies or only partially approves a request for services;
- Reduces, suspends or terminates authorization for a service you are currently authorized to receive;
- Denies payment for your authorized services;
- Fails to ensure that you receive services in a timely manner;
- Fails to meet the grievance and appeal deadlines described on this webpage;
- Fails to allow you to obtain services outside the network, but only if you live in a rural area and there is no Vaya Health network provider available to offer the services.
If you receive a notice of any of these actions, you have the right to appeal. If the decision changes an existing authorization, we must notify you at least 10 days prior to the effective date of the change. If the decision involves a new authorization (even if it is an authorization to continue a service you are currently receiving), we are not required to give advance notice.
The notice will include an appeal form and instructions for how to file your Vaya Health Request for Reconsideration and all subsequent appeals. We will not retaliate against you in any way if you appeal.
It is very important for you to follow exactly all procedures and timelines outlined in the notice. Your first step is to request a reconsideration review of the Vaya Health decision. You must go through the Vaya Health reconsideration process before filing an appeal with the North Carolina Office of Administrative Hearings (OAH).
Our Member & Caregiver Handbook provides instructions for filing a request for reconsideration:
Unlike Medicaid services, non-Medicaid services (meaning services funded with local, state or federal block grant dollars) are not a constitutional entitlement, and so the appeal rights are different.
We will notify you in writing within one business day if we make a decision to deny, reduce, suspend or terminate your non-Medicaid funded services. If you get a letter from us saying some or all of your non-Medicaid services have been reduced, suspended, terminated or denied, you can appeal the decision, except that you may not appeal denials based on lack of non-Medicaid funding for the requested service. However, you can file a grievance about these decisions. We will not authorize the requested services during an appeal period.
Our Member & Caregiver Handbook provides detailed instructions for filing a request for reconsideration:
Filing a Grievance
A grievance is any complaint or concern made by (or at the request of ) a Vaya Health member about any matter other than a decision to deny, reduce, terminate or suspend your services (called an “adverse benefit determination”). You have the right to file a grievance with Vaya Health either verbally or in writing.
To file a grievance, call the Customer Services Line at 1-888-757-5726, file online at vayahealth.ethicspoint.com (allows for anonymous reporting) or mail your grievance to:
Vaya Health Customer Services
Attn: Complaints and Grievances
P.O. Box 1049
Waynesville, NC 28786-1049
Examples of grievances include concerns about:
- Staff not keeping an appointment
- Staff being disrespectful
- Inability to access services
- Quality of care
- Member rights
- Wanting more or different services than what is allowed under your benefit plan
If you want to discuss your concern informally before filing a grievance, you can contact our Customer Services Line at 1-888-757-5726 and ask to speak with a grievance specialist. You may also share your concerns with a person working with you (if you are comfortable discussing your concerns with that person) and ask him or her to help or advise you. If you need assistance filing a grievance, our Customer Services staff will ensure you get help. Family members, friends, advocates and/or your attorney may also help you file a grievance.
When you call us to discuss your grievance, staff will make a written record on a computerized form. We will also send you a written notice acknowledging receipt of your grievance. When we receive your grievance, it is assigned to the department that can best respond to your concerns. If your grievance involves serious health and safety issues, we will notify our Chief Medical Officer and take immediate action, if needed.
If a network provider is involved with your grievance, we will try to resolve your grievance directly with the provider. You are not required to use your service provider’s grievance process first before contacting us. In order to resolve your concerns, a Vaya Health staff person will contact you and others involved with the grievance to help resolve your concerns.
Vaya Health will make every effort to resolve your grievance within 30 days from the date of receipt, but we have up to 90 days for resolution. That timeframe can be extended under federal regulation by another 14 days if justified. You will receive written notification regarding the resolution of your grievance by trackable mail. We will also notify you if we refer your grievance to another agency, such as the Division of Health Service Regulation (for licensed facilities). Please note that you cannot appeal the resolution of a grievance.
Fraud, Waste and Abuse
Vaya Health is committed to identifying, preventing and detecting fraud, waste and abuse in the Medicaid program. Fraud in public healthcare programs is a serious issue that costs the government tens of millions of dollars annually. Medicaid fraud occurs when a provider submits a false or fraudulent claim, or when a person intentionally lies or conceals income or assets in order to obtain government benefits.
Medicaid abuse occurs when a person or provider engages in activities that cause unreasonable or excessive cost to the Medicaid program. This includes a Medicaid managed care organization such as Vaya Health.
We encourage you to report any suspicious billing practices or other activity you think may be fraud or abuse. You can remain anonymous, but know that detailed information will help us with our investigation. When you contact us, please provide the name/MID of the Medicaid beneficiary involved, the name of the provider, the date(s) of service, the amount of claims billed or paid and a description of the fraudulent or suspicious activity. You can report suspected fraud and abuse in any of the following ways:
- Call the Vaya Health Confidential Compliance Hotline at 1-866-916-4255. This line is available 24 hours a day, 7 days a week and allows for anonymous reporting.
- Report online at vayahealth.ethicspoint.com (allows for anonymous reporting)
- Call the Medicaid fraud, waste and program abuse tip line at 1-877-DMA-TIP1 (1-877-362-8471)
- Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477)
- Call the North Carolina State Auditor at 1-800-730-TIPS (1-800-730-8477)