Recipient Appeals
Sometimes Vaya may decide to clinically deny, suspend, reduce, or terminate a request your provider makes for you for State-funded services covered by our plan. You will receive a letter from Vaya notifying you of any decision to deny, suspend, reduce, or terminate a service request your provider makes. The letter will include information about the reason for the decision and any available options while the appeal is under review. State-funded services recipients have the right to appeal decisions to deny, suspend, reduce, or terminate their services. Vaya must receive the appeal in writing within 15 working days from the date of the letter.
When you ask for an appeal, Vaya has seven business days to give you an answer. You can ask for an appeal yourself. You may also ask a family member, a friend, your provider, or a legal representative to help you with your appeal. It is easy to ask for an appeal by using one of the options below:
MAIL: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it, and any added information you want us to consider, to the address listed on the form. We must receive your form no later than 15 working days after the date on the notice.
FAX: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Fax it, and any added information you want us to consider, to the fax number listed on the form. We must receive your form no later than 15 working days after the date on the notice.
ONLINE: Fill out and submit the Appeal Request Form available in the Vaya Member and Recipient Portal. Attach documents you want us to consider.
PHONE: Call Member and Recipient Services at 1-800-962-9003 and ask for an appeal. If you want someone to help you, you must give them permission.
IN PERSON: You may hand-deliver an appeal to Vaya’s Asheville office at 200 Ridgefield Court, Suite 218, Asheville, NC 28806.
Other Considerations
Vaya will make a decision on your appeal within seven business days from the day we get your appeal request. We will mail you a letter to tell you about our decision.
If you do not agree with our decision, you can ask for an appeal with the NCDHHS Division of Mental Health, Developmental Disabilities, and Substance Use Services (MHDDSUS) Hearing Office. The request for an NCDHHS-level appeal must be received within 11 calendar days from the date on the letter from Vaya.
The Division of MHDDSUS Hearing Office will review your request and will issue its findings and recommended decisions. Vaya will issue a final written decision on your request that considers the Hearing Office’s findings. We make a final decision within 10 days of receiving the Panel’s findings.
Your decision letter from Vaya will include a State Non-Medicaid Appeal Request Form. To ask for an appeal with the Division of MHDDSUS Hearing Office, mail or fax the completed form to:
- BY MAIL: Division of MHDDSUS Hearing Office, c/o Customer Service and Community Rights Mail Service Center 3001, Raleigh, NC 27699-3009
- BY FAX: 984-777-9264
Continuation of Services During an Appeal
Sometimes Vaya’s decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. Vaya is not required to continue State-funded services during the appeal process.
To request to continue services during your appeal, call Vaya’s Member and Recipient Appeals Team at 1-800-893-6246, ext. 1400.