Vaya handles provider appeals of adverse determinations promptly, consistently, fairly, and in compliance with state and federal law, NCDHHS requirements, and accrediting body guidelines. Vaya strictly prohibits discrimination or retaliation against any network provider based on submission of an appeal.
Network providers have the right to appeal the following determinations:
- Administrative actions, including claim denials, payment withholdings, suspensions of payment, and overpayment notifications
- Provider sanctions, which are decisions, actions, or inactions against a network provider based on professional competence or conduct or resulting in a change to the provider’s status within the network
- Notices of credentialing action (NCA), including non-renewal of a network contract nor a non- renewal of participation as a network provider
How do I submit a provider appeal?
To file an appeal, visit our online Provider Portal (coming soon).
Appeals must be submitted in writing within 30 calendar days of the date when:
- The provider received written notice of an adverse determination at the contact information on file with Vaya (this is why it is important to keep your contact information up to date), or
- Vaya has taken an action against a provider, or
- Vaya should have taken a required action and failed to take such action.
Vaya may extend this timeframe by an additional 30 calendar days if we determine good cause has been shown.
How will my appeal be resolved?
Vaya will acknowledge receipt of the appeal request within 5 calendar days of receipt. Vaya’s provider appeals panel will review the appeal and issue a decision notice to the provider no later than 14 calendar days of receiving a complete appeal request, or, if an extension is granted to the provider to submit additional evidence, the date on which all evidence is submitted to Vaya.
This notice will include information about any further appeal rights. Providers must exhaust Vaya’s internal appeals process before seeking recourse under any other process permitted by contract or law. Providers may be represented by an attorney throughout the appeals process.