Vaya Health network providers are responsible for understanding and helping members with the appeal process. Members and legally responsible persons (LRPs), not providers, have appeal rights. However, you can file an appeal on behalf of a Medicaid beneficiary or LRP with their written, signed permission. Vaya does not engage in retaliation of any kind against a member, a network provider, a family member or other person who requests a reconsideration, appeal or expedited review.
Members or legally responsible persons (LRPs) who submit an oral request for reconsideration of a Medicaid adverse benefit determination (ABD) no longer need to follow up with a written request. All ABD notices sent to the member or LRP will continue to include the DHHS-required Reconsideration Request Review Form. Providers requesting a reconsideration of an ABD on behalf of a member may submit oral or written requests for the appeal as long as the member or LRP provides written consent authorizing them to file the appeal on their behalf.
Members and providers, acting on a member’s behalf and having the member’s or LRP’s written permission, must continue to file written (not oral) appeals of an ABD with the Office of Administrative Hearings (OAH). While providers may assist members filing a reconsideration or appeal of a non-Medicaid adverse decision, providers may not file the reconsideration or appeal on the member’s behalf.
More detailed information about the appeal process is included in our Member & Caregiver Handbook. It is very important for members to follow exactly all procedures and timelines outlined in the notice. Members must go through the Vaya reconsideration process before filing a Medicaid appeal with the OAH or non-Medicaid appeal with DMH/DD/SAS.
The first step is to request a reconsideration review of the Vaya decision. Oral or signed requests for reconsideration must be received by Vaya within 60 days of the notice for Medicaid services. Signed requests for reconsideration must be received by Vaya within 15 working days of the notice for non-Medicaid services. Requests may be submitted as follows:
- By fax at 1-833-845-5616
- By mail to Vaya Health, Attn: Member Appeals, 200 Ridgefield Court, Asheville, NC 28806
- By email to firstname.lastname@example.org
- In person at Vaya’s Asheville office, 200 Ridgefield Court, Asheville, NC 28806
- By phone at 1-800-893-6246, ext. 1400
For assistance, please call the Member Appeals Team at 1-800-893-6246, ext. 1400.
We always send an acknowledgement letter when we receive a reconsideration request, unless an expedited reconsideration is requested and accepted. If the member does not receive an acknowledgement letter, please contact us right away to follow up. Reconsideration requests are reviewed by a health care professional with appropriate clinical expertise in treating the member’s condition or disorder who was not involved in the original decision and is not a direct subordinate of the initial decisionmaker(s). As part of the process, members can request a copy of their records from Vaya, and new or additional information will be accepted and considered.
For Medicaid appeals, we will issue a written decision (called a notice of resolution) within 30 days of receipt of a timely request. The reconsideration can be expedited if we agree that a member or LRP’s request for an expedited review meets the expedited review criteria or if the ordering provider or another qualified provider with knowledge of the member’s medical condition indicates that adherence to the standard timeframe could seriously jeopardize a member’s life, health or ability to attain, maintain or regain maximum function.
If the request to expedite is necessary, we will complete the expedited review, attempt to notify the member of our decision by phone and notify you and the member by written decision within 72 hours of the request. If we do not agree that expedited review is necessary, we will notify you and the member of our decision and process it within the applicable appeal timeframe. Vaya will make reasonable efforts to provide members prompt oral notice and will provide a written notice within two calendar days when Vaya denies a request for an expedited appeal. The member/LRP may file a grievance of this decision but may not otherwise appeal the denial of a request for expedited resolution.
Similar to the process for review of service authorization requests, the timeframe to issue a written decision (for either a standard or expedited appeal) may be extended by up to 14 calendar days if the member requests the extension or Vaya demonstrates that there is need for additional information and the delay is in the member’s interest. If Vaya extends an appeal resolution timeframe, we will make reasonable efforts to give the member prompt oral notice of the delay and will notify in writing of the extension within two calendar days. If a member disagrees with the extension, they have the right to file a grievance.
For non-Medicaid appeals, we will issue a decision within seven business days of receipt of a timely request.
If a member disagrees with our decision, he or she can either: (1) for Medicaid services, file an appeal with OAH within 120 days of the date of the Vaya notice of resolution or (2) for non-Medicaid services, file an appeal with DMH/DD/SAS within 11 calendar days of the Vaya appeal decision letter date. Instructions and an appeal form are included with the decision notice.
There is no “maintenance of service” under Medicaid managed care or for non-Medicaid services. However, if Vaya reduces, suspends or terminates a current authorization, Vaya will continue a Medicaid member’s benefits if all of the following conditions are met:
- A timely request for reconsideration is made;
- The member remains Medicaid-eligible;
- The reconsideration involves the termination, suspension, or reduction of a previously authorized service;
- The services were ordered by an authorized provider;
- The authorization period for the services has not expired; and
- A timely request (meaning on or before the later of within 10 calendar days of the Notice of Adverse Benefit Determination or the intended effective date of Vaya’s proposed decision) for services to continue is made.
If the member meets all of the above conditions, and Vaya authorizes continuation of benefits, the benefits will be continued (so long as the original authorization period has not expired) until one of the following occurs:
- The member withdraws the reconsideration or appeal request;
- The member does not request a State Fair Hearing and continuation of benefits within 10 days from the date of the Notice of Resolution; or,
- A State Fair Hearing decision adverse to the member is issued.
If a member decides to appeal a Vaya decision, and the decision is upheld, Vaya has the right to recover from the member, spouse or parent (if under 18) the cost of services furnished during the reconsideration and appeal process.
Medicaid beneficiaries have the right to a second opinion if the person does not agree with the diagnosis, treatment or the medication prescribed. Members are informed of this right in our Member & Caregiver Handbook. If a second opinion is requested, you must refer the member to Vaya’s Utilization Management Department.