Vaya Health network providers are responsible for understanding and helping members with the appeal process. Members, not providers, have appeal rights. However, you can file an appeal on behalf of a member 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.
It is very important that members follow all procedures and timelines outlined below. Members must go through the Vaya reconsideration process before filing a Medicaid appeal with the Office of Administrative Hearings (OAH) or the Vaya appeal process before filing a non-Medicaid appeal with the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS).
For detailed information, please refer to our Member and Caregiver Handbook.
The first step is to request a reconsideration review or appeal of the Vaya decision. Signed requests for reconsideration must be received by Vaya within 60 days of the notice (for Medicaid services) or 15 working days of the notice for non-Medicaid services, as follows:
- By fax at 1-833-845-5616
- By mail to Vaya Health, Attn: Appeals Coordinator, 128 Sylva Plaza, Sylva, NC 28779
- By email to email@example.com
- In person at any Vaya regional office listed on our Contact Us page
- By phone at 1-800-893-6246, ext. 1400. If a request is made orally, we still must receive a signed request for reconsideration within 60 calendar days (for Medicaid) or within 15 working days (for non-Medicaid) of the date of the notice.
- For assistance, please call the Member Appeals Team at 1-800-893-6246, ext. 1400.
Vaya will send an acknowledgement letter upon receiving a standard reconsideration or appeal request. If the member does not receive an acknowledgement letter, please contact us immediately. Reconsideration and appeal requests are reviewed by a healthcare professional with appropriate clinical expertise in treating the member’s condition or disorder who was not involved in the original decision. 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 within 30 days of receipt of a valid request. For non-Medicaid appeals, we will issue a decision within seven business days of receipt of a timely request.
The reconsideration or appeal can be expedited if you believe that adherence to the standard timeframe could seriously jeopardize a member’s life, health or ability to attain, maintain or regain maximum function. If we accept a request or determine that it is necessary to expedite a reconsideration or appeal, we will complete the expedited review within 72 hours of the request and attempt to notify you and/or the member of our decision by phone. We will send a written decision no more than three days later.
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. Denial of expedited review cannot be appealed, but the member can file a grievance if he or she disagrees with our decision. Similar to the process for review of service authorization requests (SARs), 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 if Vaya demonstrates that there is a need for additional information and the delay is in the member’s interest.
If a member disagrees with our decision about Medicaid services, he or she can file an appeal with OAH within 120 days of the date of the Vaya reconsideration decision notice. If a member disagrees with our decision about non-Medicaid services, he or she can 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, benefits will continue during a Medicaid (but not non-Medicaid) appeal through the end of the original authorization period if the member requests continuation of benefits within 10 days of the decision. 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 age 18) the cost of services furnished during the reconsideration and appeal process.
Medicaid beneficiaries have the right to a second opinion if the individual does not agree with the diagnosis, treatment or medication prescribed. Members are informed of this right in the Vaya Health Member and Caregiver Handbook. If a second opinion is requested, please refer the member to Vaya’s Utilization Management (UM) Department.