As a Vaya Health network provider, you have the right to report concerns about our Tailored Plan and file grievances through a distinct provider process. Vaya strictly prohibits discrimination or retaliation against any network provider based on submission of a grievance.
A provider grievance is a verbal or written concern expressing dissatisfaction related to Medicaid or NC Health Choice services administered by Vaya or its subcontractors, except for disputes in which the provider has the right to appeal. Applicable subcontractors include Vaya’s provider of non-emergency medical transportation (NEMT) or our pharmacy benefits manager (PBM).
A provider complaint is the same as a provider grievance but is related to Vaya’s administration of state-funded (non-Medicaid) services.
To learn more about appeals of provider adverse determinations, visit our Provider Appeals page.
How do I submit a grievance or complaint?
To submit a grievance or complaint, visit our online Provider Portal. Vaya’s “no wrong door” approach also allows you to submit a grievance or complaint in any of the following ways:
EthicsPoint allows for anonymous reporting. It is an online compliance and complaint/grievance intake platform for members, community stakeholders, providers, and Vaya staff. EthicsPoint assigns an individualized report key to each case, as well as a password. You should keep this password in a safe place, as Vaya staff cannot update or retrieve passwords.
Additionally, a written grievance or complaint may be hand-delivered, faxed, emailed, or mailed to Vaya’s administrative office in Asheville or to any staff member.
Pharmacy service providers and staff may also report concerns by directly contacting the PBM through its toll-free service line, by mail, via email, or via its online portal. Vaya’s NEMT service provider and staff may also report concerns by directly contacting the NEMT provider through its toll-free service line, by mail, via email, or via its online portal.
How will my grievance or complaint be resolved?
Vaya handles provider grievances promptly, consistently, fairly, and in compliance with state and federal law. NCDHHS requirements, and accrediting body guidelines. Within 5 calendar days of receipt of the provider grievance or complaint, we will send a written acknowledgement via email to the filer(s).
Our efforts to resolve a grievance or complaint may include:
- Phone interviews with the filer to obtain additional information or clarification
- Consultation with Vaya or subcontractor staff, including licensed clinicians and subject matter experts
- Provider record request and record review
- Phone interviews with individuals who have a legitimate role in the issue to be resolved
Any Vaya or subcontractor staff member attempting to resolve the grievance or complaint cannot have been involved in any previous level of decision-making regarding the issue at hand.
Within 30 days of receipt of a provider grievance or complaint submitted via EthicsPoint, Vaya or applicable subcontractor will send a Notice of Grievance or Complaint Resolution to the filer. This notice identifies efforts made to resolve the issue, the findings, and any proposed resolution.
A grievance or complaint is considered resolved when one of the following occur:
- The filer withdraws the grievance or complaint.
- The GRIT determines the grievance or complaint is outside the purview of Vaya and/or makes a referral to an appropriate state agency or licensure board.
- Vaya or applicable subcontractor staff have taken all reasonable steps to address the grievance or complaint, and no further action can be taken to assist the filer.