A grievance or complaint is any expression of dissatisfaction about any matter (other than an adverse benefit determination) filed by a member or by an individual who has been authorized in writing to file on behalf of a member. Your family members, friends, advocates and/or your attorney may also help you file a grievance or complaint. You, or your network provider that has been authorized in writing to act on your behalf, may file requests for grievances or complaints. You will not lose your Medicaid benefits for filing a grievance or complaint.
What are examples of grievances and complaints?
Grievances and complaints could involve matters such as:
- Staff not keeping an appointment or being late to an appointment
- Staff not being respectful to you
- Concerns about provider quality of care
- Lack of access to services where you live or services that are not allowed on the benefit plan
- Attitude of Vaya staff and providers
- Billing and financial issues
- Quality of your practitioner’s office or facility
If you are unhappy with your services, you have the right to file a grievance or complaint with Vaya. Members with Medicaid have a constitutional right to due process. Due process means you are entitled to a written notice and an opportunity to be heard.
Vaya follows a “no wrong door” approach for submitting grievances or complaints. You can file a grievance or complaint in any of the following ways:
Member Services: 1-800-849-6127
If you want to discuss a grievance or complaint, you can contact Vaya during regular business hours at 1-800-849-6127. You may also share your concerns with your provider or care manager directly and ask them to help or advise you. You are not required to discuss your grievance or complaint directly with your provider before calling Vaya.
Your provider can assist you with filing a grievance or complaint, as well. However, if the provider calls to file a grievance on your behalf, the provider must have your written consent.
Once Vaya receives your grievance or complaint, we will:
- Make a written record of the grievance or complaint
- Send written acknowledgment of your grievance or complaint within five business days
- Contact you and others involved with the grievance or complaint to help resolve your concerns
- Consult the department that can best address your concerns. If your grievance or complaint involves health, safety or emergency quality of care concerns, we will take action immediately.
- Attempt to address your grievance or complaint with your provider agency; you are not required to use your service provider’s grievance process.
When your grievance or complaint has been resolved, we send you a formal resolution letter. The notification will specify if your grievance or complaint is referred to another agency, such as the state DHSR (if a licensed facility is involved). Vaya’s policy is that all grievances and complaints must be resolved within 30 calendar days of receipt. Under federal law, we have up to 90 days for resolution. This timeframe can be extended by 14 calendar days if you request the extension and Vaya determines the extension is justified.
WHAT IF I’M NOT SATISFIED WITH THE RESPONSE TO MY GRIEVANCE OR COMPLAINT?
Vaya’s policy is to offer members the right to appeal the resolution of a grievance or complaint if the member is not satisfied with the decision.
HOW DO I APPEAL A GRIEVANCE OR COMPLAINT RESOLUTION?
You will receive a resolution notice with information on how to file an appeal. You have seven calendar days from the date of the notice to request an appeal in writing, either by email, fax, regular mail or hand delivery to a Vaya regional office:
|At any Vaya office listed on our Contact Us page|
Your appeal will be reviewed within 15 calendar days from the date Vaya receives your request. Once a decision is made, Vaya will send you a written Appeal Resolution Notice, which informs you of our final decision, within the following 15 days. There is no further appeal beyond this review.
CAN I GET LEGAL ASSISTANCE?
To locate a lawyer, please call 1-800-662-7660 for the N.C. Health Information Project Lawyer Referral Service or 1-800-662-7407 for the N.C. State Bar Lawyer Referral Service. You can also call Legal Aid of North Carolina at 1-866-219-5262.