Free and Voluntary Mediations
When you ask for a State Fair Hearing, you will get a phone call from the Mediation Network of North Carolina. The Mediation Network will call you within five business days after you request a State Fair Hearing. During this call you will be offered a mediation meeting. The state offers this free meeting to help resolve your disagreement quickly. These meetings are held by phone.
You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of Vaya’s review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing.
What is a State Fair Hearing?
State Fair Hearings are held by the NC Office of Administrative Hearings. An administrative law judge will review your request along with new information you may have. The judge will make a decision on your service request.
You can give any updates and facts you need to at this hearing. A member of Vaya’s review team will attend. You may ask questions about Vaya’s decision. The judge in your State Fair Hearing is not a part of Vaya in any way.
How to Request a State Fair Hearing?
It is easy to ask for a State Fair Hearing. Use one of the options below:
- MAIL: Fill out and sign the State Fair Hearing Request Form that comes with your notice. Mail it to the address listed on the form.
- FAX: Fill out, sign, and fax the State Fair Hearing Request Form that comes with your notice. The fax number is listed on the form.
- PHONE: Call the Office of Administrative Hearings at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call.
If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court.
Disenrollment Decisions
If you disagree with a decision to change your health plan, you can ask for a State Fair Hearing. The process to ask for a State Fair Hearing for disenrollment decisions is different than the process for a State Fair Hearing when Vaya limits or denies a service that you requested. For more information, refer to your Tailored Plan Medicaid Member Handbook or NC Medicaid Direct Member Handbook.
Continuation of Benefits During an 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. 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.
