Member Appeals

Sometimes Vaya may decide to deny or limit a request your provider makes for you for Medicaid benefits or services offered by our plan. This decision is called an adverse benefit determination. You will receive a letter from Vaya notifying you of any adverse benefit determination.

Medicaid and NC Health Choice 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, a lawyer, or anyone else you authorize to help you. You can call Member Services at 1-800-962-9003 if you need help with your appeal request. 

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 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, sign, and fax the Appeal Request Form in the notice you receive about our decision. You will find 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 Member and Recipient Services at 1-800-962-9003 and ask for an appeal. When you appeal, you and any person you have chosen to help you can see the health records and criteria that Vaya used to make the decision. If you want someone to help you, you must give them permission.

IN PERSON: You may hand-deliver an appeal to Vaya’s Asheville office at 200 Ridgefield Court, Asheville, NC 28806.

Other Considerations

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.

Your provider can ask for an expedited appeal by calling our Member Appeals team at 1-800- 893-6246, ext. 1400.

You can ask for an expedited appeal by phone, by mail, or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal.

Provider Requests for Expedited Appeals

If your provider asks us for an expedited appeal, 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.

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 2 calendar days.

If you do not agree with our decision to deny an expedited appeal request, you may file a grievance with us.

When we deny a member’s 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 a member’s medical condition requires.

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 until you are ready. Ask for an extension by calling Member Services at 1-800-962-9003 or writing to:

Vaya Health, Attn: Member 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.

State Fair Hearings

If you do not agree with Vaya’s decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a free and voluntary mediation session. This meeting is held before your State Fair Hearing date.

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 5 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. If 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 to Expect 

State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). 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.

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 addresses listed on the form

FAX: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax numbers you need listed on the form.

PHONE: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 60 days after the date on the notice.

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. You can also contact the NC Medicaid Ombudsman to get more information about your options. 

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 to ask for a State Fair Hearing when Vaya limits or denies a service that you requested. 

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.

The rules in the section are the same for appeals and State Fair Hearings.

There are special rules about continuing your service during your appeal. Please read this section carefully. 

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 you the day get your appeal decision. You or your authorized representative may contact Member Services at 1-800-962-9003 or contact the Appeals Coordinator identified in your adverse benefit determination letter to ask for your service to continue until you get a decision on your appeal.

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.

Appeals During Your Transition Out of the Vaya Tailored Plan 

If you decide to leave the Vaya Tailored Plan, your appeal may be impacted by this transition. If you will be transitioning out of our plan soon and have an appeal with us, we will continue to process any part of your appeal that affects authorization of services through the date that you leave the Vaya Tailored Plan. Please contact Member Services at 1-800-962-9003 for additional information.