Medicaid beneficiaries have a constitutional right to due process. Due process means you are entitled to a written notice and an opportunity to be heard. Our Medicaid appeals system is based on this fundamental right to due process. it is important for you to follow exactly all procedures that you receive in notices and letters issued by Vaya Health, including our timelines for requesting appeals.
What types of Medicaid decisions can I appeal?
You can appeal any Medicaid “adverse benefit determination” issued by Vaya Health. An adverse benefit determination occurs if Vaya:
- Denies or partially approves a request for Medicaid services for you;
- Reduces, suspends or terminates authorization for a Medicaid service you are currently authorized to receive;
- Denies payment for your authorized Medicaid services;
- Fails to ensure that you receive Medicaid services in a timely manner;
- Fails to meet the grievance and appeal deadlines described in this section; or
- Fails to allow you to obtain Medicaid services outside the network, but only if you live in a rural area and there is no Vaya network provider who is available to provide the services.
- Denies your request to dispute a financial liability, including cost sharing, co-payments, premiums, deductibles, co-insurance and other enrollee financial liabilities.
If you receive a notice of any of these adverse benefit determinations, you can 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 it involves a new authorization (even if it is an authorization to continue a service you are currently receiving), we do not have to give you advance notice. The notice will include an appeal form and instructions for how to file your Vaya Request for Reconsideration. 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 decision. You must go through the Vaya reconsideration process before filing an appeal with the state Office of Administrative Hearings (OAH). Vaya will not retaliate against you in any way if you appeal.
To request a reconsideration of a Medicaid adverse benefit determination, you must complete and return the Vaya reconsideration request form included with the notice in any of these ways:
BY FAX:1-833-845-5616
BY MAIL: Vaya Health
Appeals Coordinator
128 Sylva Plaza
Sylva, NC 28779
BY EMAIL: member.appeals@vayahealth.com
IN PERSON: At any Vaya regional office
You can also request reconsideration orally by calling 1-800-893-6246, ext. 1400. Please note that if you request reconsideration orally, Vaya must receive a signed request for reconsideration within 60 days of the date of the adverse benefit determination notice from Vaya
Vaya must receive your signed request for reconsideration form within 60 days of the date of the notice. We will send you a written acknowledgement within one business day when we receive your request. If you have submitted a request and have not received the acknowledgement, call us and let us know. Vaya will not accept or process requests for reconsideration filed outside the timeline.
Yes. We must provide you with reasonable assistance in completing forms and taking other procedural steps related to a grievance or appeal. This includes, but is not limited to, providing auxiliary aids and services upon request, such as interpreter services and TTY/TTD capability.
Your provider, a family member or friend can also help you file the form with your written permission. For help with your appeal, please call the Vaya Member Appeals Team at 1-800-893-6246, ext. 1400. You can also call Vaya Member Services at 1-800-849-6127.
Yes. If you want a copy of your case file, free of charge, please call the Member Appeals Team at 1-800-893-6246, ext. 1400. Please let us know as soon as possible if you want a copy. The case file will include all records considered by Vaya in connection with the decision, including documents submitted by your provider. You can also submit new information at any point during the appeal process. This might include new information from your physician, such as updated assessments.
We recommend you keep good records of written correspondence with Vaya, your providers or the N.C. Division of Health Benefits. We also recommend you keep a record of telephone conversations with Vaya or your providers. Always write down:
- The date and number you called
- The name of the person with whom you spoke
- A note about the subject of the call
- When you can expect to get a response and from whom, or the name and number of another person for you to contact
You or your provider can request an expedited reconsideration review if the 30-day review period will jeopardize your health and safety. You can make this request orally or in writing. If you make an oral request, it does not have to be followed up with a written request (unlike the actual request for reconsideration). We will let you or your provider know by phone if we agree that it is necessary for your reconsideration to be expedited.
If we do not agree that your request should be expedited, you will be notified in writing and can file a grievance if you disagree. If we agree that it should be expedited, we will complete the expedited review within 72 hours of the request and attempt to let you or your provider know our decision by phone. We will send you a written decision no more than three days after that. The expedited timeframe can be extended by up to 14 days at your request or if Vaya determines that we need additional information and the extension would be in your best interest. If we extend the expedited timeframe by 14 days, we will notify you in writing within three business days of that determination.
If we approve some services but deny others, you can receive the services that were approved while you appeal the services that were denied.
You can also make a new request for different services while your appeal is pending. The services that were denied will continue during the appeal only if you timely request reconsideration and ask for continuation of benefits within 10 calendar days of the date of the notice of adverse benefit determination and the period covered by the original authorization has not expired. If the services are continued under these conditions, they will continue (so long as the original authorization period has not expired) until one of following occurs:
- You withdraw your request for reconsideration or for state fair hearing;
- You fail to request a state fair hearing and continuation of benefits within 10 calendar days after Vaya notifies you of the decision on your request for reconsideration;
- The Office of Administrative Hearings issues a decision adverse to you.
If services are continued and Vaya’s decision is upheld, we have the right to recover the cost of services furnished to you during the reconsideration and appeal process. We can recover the costs from you, your spouse or your parent (if you are under age 18).
A reconsideration review is an impartial review of Vaya’s decision to reduce, suspend, terminate or deny your Medicaid or non-Medicaid services. Your request will be reviewed by a healthcare professional with appropriate clinical expertise in treating your condition or disorder who was not involved in the original decision.
Vaya has 30 calendar days to make a reconsideration decision (called a Notice of Adverse Resolution) about your Medicaid services. This can be extended for up to 14 days at your request or if we determine that additional information is necessary and the extension would be in your best interest. If we extend the standard appeal resolution timeframe by 14 days, we will notify you in writing within three business days of that determination.
If you disagree with the Vaya reconsideration decision about your Medicaid services, you may file an appeal with the N.C. Office of Administrative Hearings (OAH) to request a state fair hearing. You must file your appeal with OAH within 120 days of the date of the Vaya reconsideration decision notice. State fair hearing appeals are heard by an administrative law judge at OAH.
To request a state fair hearing, you must submit a completed appeal form to the Clerk, Office of Administrative Hearings, at the address, fax number or email address provided on the form. Your provider, a family member or a friend can help you file the form with your written permission. Failure to file within 120 days or to follow the instructions may result in your appeal being dismissed.
If you lose the appeal form that was included with the decision, you can get another copy by calling Vaya at 1-800-893-6246, ext. 1400, or by calling OAH at 919-431-3000.
After filing your appeal, the Mediation Network of North Carolina will contact you to discuss the case and offer an opportunity for mediation. If you accept mediation, it must be completed within 25 days of the date you filed your appeal. If mediation resolves the case, the hearing will be dismissed, and services will be provided as specified by the mediation agreement.
If you decline mediation, or if you accept mediation and it is unsuccessful or if you do not show up for the scheduled mediation date, your appeal will proceed to a hearing. You will be notified by mail of the date, time and location of the hearing. You may represent yourself in the hearing process, hire an attorney or ask a relative, friend or other person to speak on your behalf. Vaya will provide you with all documents we intend to use at the hearing in advance. You can present new evidence at the hearing, although this may result in a delay. At the hearing, both sides can present evidence.
After the hearing, the administrative law judge will make a decision about your case and send you a written copy. The decision must be issued within 90 days from the date you filed your request for reconsideration with Vaya, not including the number of days you took to file for a state fair hearing. If you disagree with the judge’s decision, you may appeal your case to Superior Court.
Unlike regular Medicaid services, non-Medicaid (state-funded) services are not a constitutional entitlement, and so the appeal rights are different. You can request an appeal if Vaya issues a decision to deny, reduce, terminate or suspend a non-Medicaid service unless the denial is based on lack of funding for the requested service. Vaya will not authorize the requested services during any appeal period
Vaya is required to notify you in writing within one business day if we make a decision to deny, reduce, suspend or terminate your non-Medicaid funded services. The notice of decision will include an appeal form and information about how to file your Vaya request for reconsideration and all subsequent appeals.
You must request reconsideration with Vaya before you file any appeal with the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS).
To appeal the reduction, suspension, termination or denial of non-Medicaid benefits, you must complete and return the Vaya Non-Medicaid Services Appeal Form (included in the notice of decision mailed to you) within 15 working days of the date of your notice of decision.
Your provider cannot file the appeal for you. Please send the form by any of the following ways:
BY FAX:1-833-845-5616
BY MAIL: Vaya Health
Appeals Coordinator
128 Sylva Plaza
Sylva, NC 28779
BY EMAIL: member.appeals@vayahealth.com
IN PERSON: At any Vaya regional office
Yes. You or your provider can request an expedited reconsideration review if the standard timeframe will jeopardize your health and safety. You can make this request orally or in writing.
We will let you or your provider know by phone if we agree that it is necessary for your reconsideration to be expedited.
If we do not agree that your request should be expedited, you will be notified in writing and can file a grievance if you disagree. If we agree that it should be expedited, we will complete the expedited review within 72 hours of the request and will attempt to let you or your provider know our decision by phone. We will send you a written decision no more than three days after that.
If you disagree with the Vaya decision, you can file an appeal with the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) to request a non-Medicaid appeal hearing within 11 calendar days of the date of the Vaya decision.
To file an appeal with DMH/DD/SAS, you must mail or fax a completed Non-Medicaid Appeal Request Form to:
BY MAIL: DMH/DD/SAS Hearing Office c/o Customer Service and Community Rights Mail Service Center 3001 Raleigh, NC 27699-3001
BY FAX: 919-733-4962
The appeal form is included in the Vaya decision letter. If you cannot find the form, you can get a copy by calling our Member Appeals Team at 1-800-893-6246, ext. 1400.
Remember: DMH/DD/SAS must receive your Non-Medicaid Appeal Request Form no later than 11 days from the date of the Vaya appeal decision letter.
Appeals are heard by a DMH/DD/SAS hearing officer. If you have questions about the DMH appeal process, please call the division at 919-715-3197. Upon receipt of your request, DMH/DD/SAS will review the appeal and decide whether it is timely and meets requirements to be accepted.
If the appeal is accepted, someone from DMH/DD/SAS will contact you to schedule a non-Medicaid appeal hearing and will also contact Vaya to request documentation we used in the initial decision and reconsideration.
The non-Medicaid appeal hearing is conducted in person by a DMH/DD/SAS hearing officer at a Vaya office and will last no more than two hours. You and your representatives can attend, along with representatives of Vaya.
Within 60 days of the written request for appeal, the hearing officer will issue a written decision that includes findings, decisions and recommendations to you or your legal representative and the Vaya CEO. Within 10 calendar days of receipt of the hearing officer’s findings, Vaya will issue and send a written final decision to you or your legal representative.
