Recipient Appeals
Sometimes Vaya may decide to deny, suspend, reduce, or terminate a request your provider makes for you for state-funded services covered by our plan. You will receive a letter from Vaya notifying you of any decision to deny, suspend, reduce, or terminate a service request your provider makes. The letter will include information about the reason for the decision and any available options while the appeal is under review. State-funded services recipients have the right to appeal decisions to deny, suspend, reduce, or terminate their services. Vaya must receive the appeal in writing within 15 working days from the date of the letter.
You or your legal guardian can ask for an appeal. You can call Vaya at 1-800-962-9003. You can ask a family member, a friend, your provider, or a legal representative to help you with your appeal. It is easy to ask for an appeal by using one of the options below:
MAIL: Fill out and sign the appeal request in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 15 working days after the date on the notice.
FAX: Fill out, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form. We must receive your form no later than 15 working days after the date on the notice.
EMAIL: Fill out, sign, and email the Appeal Request Form in the notice you receive about our decision. You will find the email listed on the form. We must receive your form no later than 15 working days after the date on the notice.
Other Considerations
When you ask for an appeal with Vaya, Vaya has 7 business days from the day that we get your appeal request to make a decision on your appeal. We will mail you a letter that explains our decision.
When we decide your appeal, we will send you a letter. If you do not agree with our decision, you can ask for an appeal with the NCDHHS Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (MHDDSAS) Appeals Panel by mailing or faxing a completed Non-Medicaid Appeal Request Form to:
- BY MAIL: Division of MHDDSAS Hearing Office, c/o Customer Service and Community Rights Mail Service Center 3001, Raleigh, NC 27699-3001
- BY FAX: 919-733-4962
The request for a state level appeal must be received within 11 calendar days from the date of the letter from Vaya.
State Appeals Panel (Division of MHDDSAS Non-Medicaid Appeals Panel)
The state appeals panel will review your request and issue a decision on your service request. Vaya will make a final decision on your request that is informed by the state appeals panel decision. We will make a final decision within 10 days of the panel’s decision.
Continuation of Services During an Appeal
Sometimes Vaya’s decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished by calling Member and Recipient Services at 1-800-962-9003. Vaya is not required to continue state-funded services during the appeal process.