Appeals

A Medicaid appeal means “a request for review of an adverse benefit determination.”

An adverse benefit determination is issued for Medicaid services only and occurs whenever:

• Vaya denies or partially denies a request for services for you
• Vaya reduces, suspends (pauses) or terminates (ends) authorization for a service you are currently authorized to receive
• Vaya denies the whole payment or partial payment for your authorized services
• Vaya fails to ensure that you receive services in a timely manner, as defined by the state
• Vaya denies your request to dispute a financial liability (or responsibility), including cost sharing, copayments, premiums, deductibles, coinsurance and other financial liabilities
• Vaya fails to allow you to get services outside the network, but only if you live in a rural area and there is no network provider available to provide the service

If Vaya makes an adverse benefit determination, we will send you or your guardian a letter (Notice of Adverse Benefit Determination). If Vaya reduces, suspends (pauses) or terminates (ends) a current, unexpired service authorization, Vaya will notify you in writing at least 10 calendar days before the effective date of the change. If Vaya denies a request for a new service or a request for a service for a new authorization period, Vaya will notify you in writing after the denial decision is made. The Notice of Adverse Benefit Determination explains:

• The adverse benefit determination
• The reason for the adverse benefit determination
• Your right to receive upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to Vaya’s decision
• Your right to request an appeal first through Vaya’s reconsideration review process and then through the Office of Administrative Hearings (OAH)
• When an appeal may be expedited and how to request an expedited review
• Your right to have services that are reduced, suspended (paused) or terminated (ended) continue until the appeal is resolved so long as the original authorization period has not expired)
• How and/or when you may exercise these rights
• If services are continued and Vaya’s decision is upheld, you may be required to pay the cost of services furnished to you during the reconsideration process.

If you receive a Notice of Adverse Benefit Determination, you can appeal. In some cases, if you properly appeal the adverse benefit determination by following the instructions in the letter, your services will continue through the end of the original authorization period.

Note: If you appeal a denial or partial denial of a request for a new service or for a new authorization period, Vaya will not continue to authorize the requested service during an appeal period.

Vaya will not retaliate against you in any way if you appeal.

A Medicaid appeal can be filed by you, your guardian or a representative, including your provider. For a representative (i.e. anyone other than you or your guardian) to represent you in an appeal, you must give your written consent (or permission) for the representative to act on your behalf and to submit a reconsideration review request.

Any oral or written request can initiate the appeal process, so long as the request provides sufficient information necessary for Vaya to consider the appeal. Your Notice of Adverse Benefit Determination includes an appeal form and instructions called a Reconsideration Request Form. The Reconsideration Request Form tells you how to file your Vaya request for reconsideration.

To protect your right to appeal, it is very important for you to follow all instructions and timelines given in the notice. If you wish to appeal a Vaya adverse benefit determination, you must first submit a request for a reconsideration review.

HOW MUCH TIME DO I HAVE TO FILE MY APPEAL?

You, your guardian or your authorized representative has 60 calendar days from the mailing date of your Notice of Adverse Benefit Determination to request Vaya to reconsider its adverse benefit determination. Your request will be on time if Vaya receives the request within the 60-calendar day period.

WHERE DO I SEND MY APPEAL REQUEST?

Submit the completed Reconsideration Request Form or your written request to any of the following:

You can also request reconsideration orally by calling 1-800-893-6246, ext. 1400.

We will send you a written acknowledgement within one business day when we receive your routine request (expedited appeal requests do not receive written acknowledgements due to the quick turnaround time). If you have submitted a request and have not received the acknowledgement, call us at 1-800-893-6246, ext. 1400, and let us know. Please note that we will not accept or process requests for reconsideration filed outside the timeline.

CAN I GET HELP WITH FILING MY MEDICAID APPEAL?

Yes. A Member Appeals Team is available to help explain and complete your appeal documentation, if requested by you, your legal guardian or your authorized representative. We will 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 (assistive) aids and services upon request, such as interpreter services and TTY/TTD capability.

For help with your appeal, you can call Vaya at 1-800-893-6246, ext. 1400, to speak with someone from the Member Appeals Team. You can also call Vaya’s Access to Care Line at 1-800-849-6127.

Vaya does not punish or retaliate against you or the provider who either requests or supports a member appeal. Vaya does not discourage, coerce (force) or misinform (give wrong information to) you regarding the type, amount and duration (length) of services you may request. In addition, Vaya does not discourage, coerce (force) or misinform (give wrong information to) members about your right to appeal.

CAN I GET A COPY OF MY RECORDS AND SUBMIT MORE INFORMATION DURING THE APPEAL?

Yes. We absolutely encourage you to submit current and relevant documentation and information to support your request for the services under appeal. 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 or used 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.

All appeal records are kept by Vaya for a minimum of five years after resolution. There must be no future litigation or audits for these records to be destroyed.

A Vaya reconsideration review is an impartial review of Vaya’s adverse benefit determination. 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 initial review or adverse benefit determination and who is not a direct employee of the initial reviewer or decision maker.

HOW LONG WILL THE RECONSIDERATION REVIEW TAKE?

Vaya has 30 calendar days to make a reconsideration decision and send you written notice (called a Notice of Resolution) about your Medicaid services. This can be extended for up to 14 days at your or your provider’s request, or if Vaya determines that additional information is necessary and that the extension would be in your best interest.

When Vaya extends timeframes, but you did not request the extension, Vaya will:

• Give you written notice of the reason for the extension within two calendar days
• Make a reasonable effort to provide prompt oral (by telephone) notification of the delay
• Resolve the appeal as quickly as your health condition requires and no later than the date the extension expires

You may file a grievance if you disagree with the decision to extend the timeframe.

CAN MY RECONSIDERATION REVIEW REQUEST BE EXPEDITED?

You or your provider may request to expedite (speed up) the reconsideration process if the 30-calendar-day timeframe Vaya has to make a reconsideration decision could seriously jeopardize your health and safety. You can request an expedited reconsideration orally or in writing. A Vaya clinician will approve or deny your request to expedite your reconsideration review.

If Vaya denies your request for an expedited reconsideration review, we will:

• Give you written notice of the reason for not expediting your request within two calendar days of the decision to not expedite the review
• Make a reasonable effort to provide prompt oral (by telephone) notification of the decision to not expedite the review
• Resolve the appeal as quickly as your health condition requires and no later than 30 calendar days (plus possible 14-day extension if necessary) from receipt of a complete request

You may file a grievance if you disagree with Vaya’s decision NOT to expedite your request. When denied, the reconsideration will be processed within the standard timeframe of 30 calendar days (which may be extended up to 14 days).

If Vaya approves your request for an expedited reconsideration review, Vaya has 72 hours from time of receipt of the request to make an expedited reconsideration decision and notify you 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 that the extension would be in your best interest.

When Vaya extends timeframes, but you did not request the extension, Vaya will:

• Give you written notice of the reason for the extension within two calendar days
• Make a reasonable effort to provide prompt oral (by telephone) notification of the delay
• Resolve the appeal as quickly as your health condition requires and no later than the date the extension expires

CAN I RECEIVE SERVICES DURING MY RECONSIDERATION REVIEW?

If we approve some services but deny others, you can receive the services that were approved in the amount, scope and duration approved while you appeal the services that were denied. You can also make a new request for services while your appeal is pending.

Federal law also allows you to continue receiving services when you appeal an adverse benefit determination to reduce, suspend (pause) or terminate (end) your services (so long as the original authorization period has not expired). If you wish for existing services to continue without interruption while you appeal a Medicaid reduction, suspension (pause) or termination (end), and the original authorization period covering the existing services has not expired, you must request Vaya reconsideration and ask for continuation of benefits within 10 calendar days of the date of the Notice of Adverse Benefit Determination.

If you request a reconsideration review after the 10th calendar day from the date of the adverse benefit determination letter, there could be an interruption in your current services.

Federal law explains this in much more detail. It says that if Vaya terminates, suspends or reduces your current Medicaid services before the expiration of the authorization period, you may continue to receive those Medicaid services if you meet all of the following conditions:

• You submit a Reconsideration Review Request Form within 60 days of the mailing date of the Notice of Adverse Benefit Determination;
• The reconsideration review involves the termination, suspension or reduction of currently authorized services;
• The services were ordered by an authorized provider;
• The authorization period for the services has not expired; and
• You timely request that your services continue on or before the later of:
  • Within 10 calendar days of the date of the adverse benefit determination; or
  • The intended effective date of Vaya’s proposed adverse benefit determination

If all of these conditions are met, you may continue to receive your current services (so long as the original authorization period has not expired) until:

• You withdraw your request for a reconsideration review or State Fair Hearing; or
• You fail to request a State Fair Hearing with the N.C. Office of Administrative Hearing (OAH) and to continue your services within 10 calendar days after the Notice of Resolution is sent to you; or
• A State Fair Hearing decision adverse to you is made.

Vaya will mail you a written letter called a Notice of Resolution within the standard, expedited or extended timeframe that applies to the reconsideration review. The Notice of Resolution explains:

• Vaya’s decision to uphold, reverse or partially uphold/partially reverse the original adverse benefit determination
• The reason for Vaya’s decision
• The date the resolution process was completed
• For appeals not resolved wholly in your favor, your right to request a State Fair Hearing
• For appeals not resolved wholly in your favor, your right to have services that are reduced, suspended (paused) or terminated (ended) continue until the appeal is resolved
• How you may exercise these rights
• For appeals not resolved wholly in your favor, if services are continued and Vaya’s decision is upheld, we have a right to recover the cost of services furnished to you during the reconsideration and appeal process. Note that we can recover the costs from you, your spouse or your parent (if you under 18).
• Vaya will attempt to notify you by phone of the outcome of an expedited reconsideration within 72 hours of receiving an expedited appeal request. We will also provide written notification of the outcome to you/your legally responsible person/personal representative and your provider within 72 hours of receiving the expedited appeal request. This written notification will include all of the same information described above for notification of a routine reconsideration decision.

If you do not agree with the outcome of the reconsideration, you can file a formal appeal with the N.C. Office of Administrative Hearings (OAH) to request a State Fair Hearing. The request for State Fair Hearing must be made to OAH within 120 calendar days of the mailing date of the reconsideration review decision (the Notice of Resolution). Formal appeals are heard by an administrative law judge with OAH.

If you wish to request a Medicaid State Fair Hearing, you must submit a completed and signed appeal form (a fillable form is included with your Notice of Resolution) to the Clerk, Office of Administrative Hearings, and to Vaya, at their addresses, emails or fax numbers listed on the form. If you lose the appeal form that was included with the decision letter, you can get another copy by calling us at 1-800-893-6246, ext. 1400, or by calling OAH at 919-431-3000.

After you request a State Fair Hearing, OAH or the Mediation Network of North Carolina will contact you to offer you the option to have your case mediated by a mediator. A mediation is an informal meeting to attempt to resolve a formal appeal before it is heard by the administrative law judge. If you accept mediation, it must be completed within 25 days of your formal appeal submission. If mediation resolves the case, the hearing will be dismissed, and services will be provided as specified by the mediation agreement.

If you agree to mediation and fail to show up, OAH will dismiss your appeal and it will not proceed to a hearing. If you decline mediation, or you accept mediation and it is unsuccessful, your formal appeal will proceed to a hearing. You will be notified by mail of the date, time and location of the hearing.

In the hearing process, you may represent yourself, hire an attorney or ask a relative, friend or other spokesperson to represent you or speak on your behalf. We 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.

The administrative law judge will make a decision regarding your case. You should receive a written copy of the decision 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 administrative law judge’s final decision, you may retain an attorney and appeal your case in Superior Court.

WHO IS RESPONSIBLE FOR MY SERVICES WHILE MY APPEAL IS PENDING?

If the final decision is not in your favor (Vaya’s reduction, suspension, termination or denial is upheld), then Vaya may elect to recover from you the cost of the services furnished to you during the formal appeal process.

Unlike Medicaid services, state law makes clear that there is no entitlement to non-Medicaid services, and the appeal rights are different. In general, you may request an appeal if Vaya issues a clinical decision to deny, reduce, terminate or suspend a non-Medicaid service. Vaya is required to notify you in writing within one business day if we make a clinical decision to deny, reduce, suspend or terminate your non-Medicaid services. If you get a letter (Notice of Decision) from us saying some or all of your non-Medicaid services have been reduced, suspended, terminated or denied, you can appeal the decision.

This notice of decision will include an appeal form and information about how to file your Vaya appeal request and all subsequent appeals. You must file an appeal with Vaya before you file an 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 return a completed and signed Non-Medicaid Services Appeal Form (included in the notice of decision mailed to you) to any of the following within 15 business days of the date of your notice of decision. Your provider cannot file the appeal for you.

Send the form to:

A Vaya appeal is an impartial review of the decision to reduce, suspend, terminate or deny your non-Medicaid services. A healthcare professional with appropriate clinical expertise in treating your condition or disorder who was not involved in the original decision will decide the appeal.

Vaya will decide your appeal within seven business days of receipt of a valid request. Services will not be authorized during the review.

CAN MY NON-MEDICAID APPEAL REVIEW REQUEST BE EXPEDITED?

You may request to expedite (speed up) the appeal process if the seven-business day timeframe will seriously harm your health and safety. You can request an expedited appeal by asking for one orally or in writing.

If you make an oral request for expedited review, it does not have to be followed up with a written request (unlike the standard request for appeal). A Vaya clinician will approve or deny your request to expedite your appeal review request.

You may submit your request to expedite the review in one of the following ways:

If you request an expedited appeal, and Vaya denies it, we will notify you by telephone or in writing of the decision NOT to expedite the request. If we agree that it should be expedited, we will complete the expedited review within 72 hours of the request and let you or your provider know our decision by telephone.

We will send you a written decision no more than three days after the decision.

WHAT IF I DISAGREE WITH THE DECISION?

If you disagree with the appeal decision, you may 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 appeal decision letter date. 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 Non-Medicaid Appeal Request Form is included in the decision letter. Remember: DMH/DD/SAS must receive the 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 at a Vaya office location. If you have questions about the appeal process, please call DMH/DD/SAS at 919-715-3197. Upon receipt of an appeal request, DMH/DD/SAS will:

• Review the appeal to determine your eligibility to appeal
• Accept or deny the appeal. If the appeal is accepted, the office will contact you to schedule a non-Medicaid appeal hearing (with at least 15 days notice)
• Request documentation from Vaya used in the initial decision and appeal

Within 60 days of the written request for appeal, the DMH/DD/SAS hearing officer will issue a written decision that includes findings, decisions and recommendations to you or your legal representative and the Vaya Chief Executive Officer. 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.

Vaya ensures members are not discouraged, coerced (forced) or misinformed (given wrong information) about the type, amount and duration (length) of services they may request. In addition, Vaya does not discourage, coerce (force) or misinform (give wrong information to) members about the right to appeal the denial, reduction, suspension or termination (stopping) of a service.

It is important for you to keep good records of written correspondence and phone conversations. We recommend that you keep every letter you receive from Vaya, your providers, the N.C. Division of Health Benefits, DMH/DD/SAS or OAH, and a record of telephone calls. You should 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 a response and from whom, or the name and number of another person for you to contact

Store your telephone log sheet and letters in a safe place.