What is a grievance?
A grievance is a complaint or concern about any matter other than a decision to deny, reduce, terminate or suspend your services (which are called “adverse benefit determinations”). Examples of grievances include concerns about:
- Health and safety
- Provider quality of care
- Provider staff not keeping an appointment
- Lack of respect from Vaya or provider staff
- Not being able to get help from someone who speaks your language
- Lack of care services where you live
- Wanting more or different services than what is allowed under the benefit plan
You have the right to file a grievance with Vaya either verbally or in writing. To file a grievance, call Vaya Customer Services at 1-800-849-6127. You can also send an email to email@example.com or mail your grievance to: Vaya Health, Attention:
Vaya Health Complaints and Grievances
200 Ridgefield Court, Suite 206
Asheville, NC 28806
You can also file a grievance in our EthicsPoint compliance portal. This website allows you to file a grievance anonymously, if you wish.
If you want to discuss your concern informally before filing a grievance, you can contact our Customer Services Department at 1-800-849-6127 and ask to speak with a grievance specialist. You may also share your concerns with your care coordinator or another person working with you (if you are comfortable discussing your concerns with that person).
If you need assistance filing a grievance, our Customer Services representatives will ensure you get help. Family members, friends, advocates and/or your attorney may also help you file a grievance.
When you call to report a complaint or grievance, Vaya staff will make a written record of your concern. We will send you a written notice acknowledging receipt of your grievance within five calendar days from the date your grievance is logged. When Vaya receives 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 Vaya network provider is involved with your grievance, we will try to resolve your grievance directly with the provider. However, you are not required to use your service provider’s grievance process first before contacting Vaya.
To resolve your concerns, a Vaya staff person will contact you and others involved with the grievance to help resolve your concerns. This may include:
- Talking with you or your legally responsible person (LRP), if applicable
- Talking to your provider or others involved in the situation
- Consulting with experts at Vaya, such as our Chief Medical Officer or legal counsel
- Reviewing your medical record to obtain information related to your grievance
We will make every effort to resolve your grievance within 30 days from the date of receipt. Under federal law, we have up to 90 days for resolution, and that timeframe can be extended by another 14 days if you request an extension or we believe an extension is justified and document the reason for the extension.
We will mail you a written notification explaining the resolution of your grievance. The notification will specify if your grievance is referred to another agency, such as the state Division of Health Service Regulation (if a licensed facility is involved). You cannot appeal the resolution of a grievance.