Sometimes Vaya may decide to deny or limit a request your provider makes for you for Medicaid benefits or services offered by our health plan. This decision is called an adverse benefit determination. You will receive a letter from Vaya notifying you of any adverse benefit determination.
Medicaid members have a right to appeal adverse benefit determinations to Vaya. You have 60 days from the date on your letter to ask for an appeal. When members do not agree with our decisions on an appeal, they can ask the NC Office of Administrative Hearings for a State Fair Hearing.
When you ask for an appeal, Vaya has 30 days to give you an answer. You can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do that in person, in writing, or by phone.
You can ask for an appeal yourself. You may also ask a friend, a family member, your provider, or a lawyer to help you. You can call our Member and Recipient Service Line at 1-800-962-9003 if you need help with your appeal request.
How can I submit an appeal?
It’s easy to ask for an appeal by using one of the options below:
MAIL: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it, and any additional information you want us to consider, to the address listed on the form. We must receive your form no later than 60 days after the date on the notice.
FAX: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Fax it, and any additional information you want us to consider, to the fax number listed on the form. We must receive your form no later than 60 days after the date on the notice.
PHONE: Call our Member and Recipient Service Line at 1-800-962-9003 and ask for an appeal.
IN PERSON: You may hand-deliver an appeal to Vaya’s Asheville office at 200 Ridgefield Court, Suite 218, Asheville, NC 28806.
ONLINE: Fill out and submit the Appeal Request Form available in the Vaya Member and Recipient Portal. Attach any documents you want us to consider.
Timelines for appeal decisions
Expedited (faster) appeals
You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health or to your ability to attain, maintain, or regain your good health. This faster review is called an expedited appeal.
You and your provider can ask for an expedited appeal by calling our Member and Recipient Appeals Team at 1-800-893-6246, ext. 1400.
You can ask for an expedited appeal in writing, online, by phone, or in person. There are instructions with your Appeal Request Form that will tell you how to ask for an expedited appeal.
Member requests for expedited appeals
Vaya will review all member requests for expedited appeals. If your request for an expedited appeal is denied, we will call you during our business hours promptly following our decision. We also will tell you and the provider in writing if your request for an expedited appeal is denied. We will tell you the reason for the decision. Vaya will mail you a written notice within two calendar days.
If you do not agree with our decision to deny an expedited appeal request, you may file a grievance with us.
If we deny your request for an expedited appeal, there is no need to make another appeal request. The appeal will be decided within 30 days of your request. In all cases, we will review appeals as fast as your condition requires.
If we accept your request for an expedited appeal, we will make a decision no later than 72 hours after we get the request. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within 72 hours from when we received the expedited appeal request.
Provider requests for expedited appeals
If your provider indicates that the appeal meets expedited review criteria, we will make a decision no later than 72 hours after we get the request for an expedited appeal. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within 72 hours from the day we received the expedited appeal request.
Timelines for standard appeals
If we have all the information we need, we will make a decision on your appeal within 30 days from the day we get your appeal request. We will mail you a letter to tell you about our decision. If we need more information to decide about your appeal, we:
- Will write to you and tell you what information is needed;
- Will explain why the delay is in your best interest; and
- May take an additional 14 days to decide your appeal if you request it or there is a need for additional information and the delay is in your best interest.
If you need more time to gather records and updates from your provider, just ask. You or someone you name may ask us to delay your case for up to 14 days. You or your provider can ask for an extension by calling Vaya’s Member and Recipient Appeals Team at 1-800-893-6246, ext. 1400; emailing member.appeals@vayahealth.com; or writing to: Vaya Health, Attn: Member and Recipient Appeals Team, 200 Ridgefield Court, Suite 218, Asheville, NC 28806.
Decisions on appeals
When we decide your appeal, we will send you a letter. This letter is called a Notice of Decision. If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the date on the Notice of Decision. Learn more about State Fair Hearings.
Continuation of benefits during your 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. You can also ask the person helping you with your appeal to make that request for you. However, your provider cannot ask for your services to continue during an appeal.
You will get a notice if Vaya is going to reduce or stop a service you are receiving. You have 10 calendar days from the date we send the letter to ask for your services to continue. The notice you get will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal.
If you ask for your services to continue, Vaya will continue your services from the day you ask for them to continue until the day you get your appeal decision.
Your appeal might not change the decision that Vaya made about your services. When this happens, Medicaid allows Vaya to bill you for services we paid for during your appeal. We must get approval from NC Medicaid before we can bill you for services we paid for during your appeal.
