Appeals & Grievances

Filing an Appeal

We want you to understand your rights to request appeals. Please remember it is crucial to follow exactly all procedures that come to you in notices and letters we issue, including timelines for requesting appeals.

Under the U.S. Supreme Court, a Medicaid beneficiary has a constitutional right to due process before a Medicaid benefit is taken away.

Due process means you are entitled to a written notice and an opportunity to have your situation heard. Our Medicaid appeals system is based on this fundamental right to due process.

You can appeal any “managed care action” issued by Vaya Health. A managed care action occurs whenever Vaya Health:

  1. Denies or only partially approves a request for services, unless Vaya Health has authorized the maximum benefits allowed for an adult under the applicable benefit plan
  2. Reduces, suspends or terminates authorization for a service you are currently authorized to receive
  3. Denies payment for your authorized services
  4. Fails to ensure that you receive services in a timely manner
  5. Fails to meet the grievance and appeal deadlines described in this section
  6. Fails to allow you to obtain services outside the network, but only if you live in a rural area and there is no Vaya Health network provider available to offer the services.

If you receive a notice of any of these actions, you have the right to appeal. If the decision changes an existing authorization, we must notify you at least 10 days prior to the effective date of change. If the decision involves a new authorization (even if it is an authorization to continue a service you are currently receiving), we are not required to give advance notice.

The notice will include an appeal form and instructions for how to file your Vaya Health Request for Reconsideration and all subsequent appeals. We will not retaliate against you in any way if you appeal.

It is very important for you to follow exactly all procedures and timelines outlined in the notice. Your first step is to request a reconsideration review of the Vaya Health decision. You must go through the Vaya Health reconsideration process before filing an appeal with the Office of Administrative Hearings (OAH).

Our Consumer Handbook provides instructions for filing a request for consideration:

pdf-1   Consumer Handbook

pdf-1   Manual del Usario

Unlike regular Medicaid services, non-Medicaid (state-funded) services and Medicaid (b)(3) services are not a constitutional entitlement, and so the appeal rights are different.

In general, you may request an appeal if Vaya Health issues a decision to deny, reduce, terminate or suspend a state-funded service. In general, you may not appeal a denial for requests for (b)(3) services or denials based on lack of state funding for the requested service. However, you can file a grievance about these decisions. We will not authorize the requested services during an appeal period.

We are required to notify you in writing within one business day if we make a decision to deny, reduce, suspend or terminate your non-Medicaid funded services. If you get a letter from us saying some or all of your non-Medicaid services have been reduced, suspended, terminated or denied, you can appeal the decision, except as outlined above.

Our Consumer Handbook provides instructions for filing a request for consideration:

pdf-1   Consumer Handbook

pdf-1   Manual del Usario

Filing a Grievance

A grievance is a complaint or concern made by or on behalf of one of Vaya Health’s Health Plan members about any matter other than a decision to deny, reduce, terminate or suspend your services (called “actions”). You have the right to file a grievance with Vaya Health, either verbally or in writing.

To file a grievance, call the Customer Services Line at 1-888-757-5726 or mail your grievance to:

Vaya Health, Healthcare Quality Systems Department
Attn: Complaints and Grievances
PO Box 1049
Waynesville, NC 28786-1049

Examples of grievances include concerns about:

  • Staff not keeping an appointment
  • Staff not showing respect
  • Inability to get help from someone who speaks your language
  • Quality of care or access to services
  • Quality of your practitioner’s office
  • Wanting more or different services than what is allowed under your benefit plan

If you want to discuss your concern informally before filing a grievance, you can contact our Customer Services Line at 1-888-757-5726 and ask to speak with a grievance specialist. You may also share your concerns with a person working with you (if you are comfortable discussing your concerns with that person) and ask him or her to help or advise you. If you need assistance filing a grievance, our Customer Services staff will ensure you get help. Family members, friends, advocates and/or your attorney may also help you file a grievance.

When you call us to discuss your grievance, staff will make a written record on a computerized form. We will send you a written notice acknowledging receipt of your grievance within five calendar days. When we receive your grievance, it is assigned to the department that can best respond to your concerns. If your grievance involves serious health and safety issues, we will notify our chief medical officer and take immediate action, if needed.

If a network provider is involved with your grievance, we will try to resolve your grievance directly with the provider. You are not required to use your service provider’s grievance process first before contacting us. In order to resolve your concerns, a Vaya Health staff person will contact you and others involved with the grievance to help resolve your concerns.

Vaya Health will make every effort to resolve your grievance within 30 days from the date of receipt, but we have up to 90 days for resolution. That timeframe can be extended under federal regulation by another 14 days if justified. You will receive written notification regarding the resolution of your grievance by trackable mail. We will also notify you if we refer your grievance to another agency, such as the Division of Health Service Regulation (for licensed facilities). Please note that you cannot appeal the resolution of a grievance.


Fraud, Waste and Abuse

Vaya Health is committed to identifying and preventing fraud and abuse in the Medicaid program. The federal government estimates fraud and abuse cost U.S. taxpayers more than $15 billion every year.

Medicaid fraud occurs when a provider submits a false or fraudulent claim, or when a person intentionally lies or conceals income or assets in order to obtain government benefits.

Medicaid abuse occurs when a person or provider engages in activities that cause unreasonable or excessive cost to the Medicaid program. This includes a Medicaid managed care organization such as Vaya Health.

We encourage you to report any suspicious billing practices or other activity you think may be fraud or abuse. You can remain anonymous, but know that detailed information will help us with our investigation. When you contact us, please provide the name/MID of the Medicaid beneficiary involved, the name of the provider, the date(s) of service, the amount of claims billed or paid and a description of the fraudulent or suspicious activity. You can report suspected fraud and abuse in any of the following ways:

  1. Call the Vaya Health Confidential Compliance Hotline at 1-866-916-4255. This line is available 24 hours a day, 7 days a week and allows for anonymous reporting.
  1. Report online at https://www.integrity-helpline.com/smc.jsp (allows for anonymous reporting)
  1. Call the Medicaid fraud, waste and program abuse tip line at 1-877-DMA-TIP1 (1-877-362-8471)
  1. Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477)
  1. Call the North Carolina State Auditor at 1-800-730-TIPS (1-800-730-8477)

Call 1-800-849-6127 toll free 24/7 to obtain services and support for mental health, developmental disabilities and substance abuse. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.