Provider Appeals

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 

Out-of-network (OON) providers have the right to appeal a claim denial, an OON payment arrangement (such as a single case agreement), a finding of waste or abuse, or an overpayment notification. 
 

How do I request an appeal review?  

To file an appeal, visit our online Provider Portal. OON providers without access to the portal should follow the instructions in the notice of the adverse determination to request an appeal. 

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.  

At the same time as the appeal request, you must electronically submit any documentation you would like the appeal review panel to consider. 

How will my appeal be resolved?  

Vaya will acknowledge receipt of the appeal request within five calendar days of receipt. Depending on the appeal type and level, Vaya conducts appeal reviews virtually by video conference, in person, or through a paper (desk) review. 

Vaya’s provider appeals panel will review the appeal and issue a decision notice to the provider no later than 30 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. In cases involving a claim denial or provider sanction, providers may request a second-level appeal review with Vaya. 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. 
 

Additional information for appeals of claim denials 

Notifications of claim denials are provided by the remittance advice (RA) or by other final notification of payment, payment denial, disallowance, payment adjustment, or notice of program or institutional reimbursement.  

Providers who wish to dispute a claim denial must submit an appeal request within the Vaya Provider Portal. OON providers without access to the portal may submit a completed Request for Claims Denial Appeal Review (Level 1). If Vaya does not receive a signed and completed Level 1 form within the required 30-day period, our action to deny the claim becomes final without further written notification. 

The appeal request must include all claim(s) specifics, including, but not limited to, the member’s/recipient’s name, member/recipient record number, date of service, service code, claim header information, RA, and any other relevant information deemed necessary for identification of a specific claim. The provider must complete all fields for the request to be accepted. Multiple claim denials may be appealed in one request. 

Level 1 requests undergo a desk review process. Vaya will schedule a Level 1 Desk Review panel meeting within 14 days (not including paid holidays) from the receipt of the signed, complete, and timely Level 1 form unless there are documented extenuating circumstances for you or for Vaya. 

Following the desk review, Vaya will uphold, overturn, or adjust the initial decision or determine that more information is needed. The panel will issue this written decision within 30 days of the date of receipt of the completed appeal request. Providers who are dissatisfied with the Level 1 appeal decision may submit a written request for a Level 2 appeal review.