Common use of COMPLAINT AND GRIEVANCE PROCEDURE Clause in Contracts

COMPLAINT AND GRIEVANCE PROCEDURE. Members are entitled to present complaints and grievances involving Benefits, Plan and EAP Providers to Plan, and Plan is obliged to seek to resolve such complaints and grievances. Plan has established a procedure for processing and resolving Member complaints and grievances. A copy of this procedure, and the form to be used to file a complaint or grievance, are available from Plan and from all EAP Providers and EAP Provider locations. A grievance is a written or oral expression of dissatisfaction regarding Plan and/or an EAP Provider, including quality of care concerns, and includes a complaint, dispute, request for reconsideration or appeal made by a Member or the Member’s representative. A complaint is the same as a grievance. There is no discrimination by Plan against a Member for filing a grievance. Members are entitled to present complaints and grievances. Plan is obliged to seek to resolve such complaints and grievances in a timely fashion. Members may file a grievance up to 365 calendar days following an incident or action that is the subject of the member’s dissatisfaction. Plan has established a procedure for processing and resolving Member complaints and grievances. Should a Member desire to register a complaint or grievance with Plan concerning Benefits, he/she can either call Plan at the toll-free telephone number ▇-▇▇▇-▇▇▇-▇▇▇▇ to report the complaint or grievance, or to request a copy of Plan’s Complaint Form, or write directly to Plan at ▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇. The telephone call or letter should be addressed to the Director, Clinical Quality Improvement. Plan will acknowledge each complaint and grievance within five (5) days of receipt. The Director, Clinical Quality Improvement, will receive and investigate all Member complaints and grievances. The Director, Clinical Quality Improvement, will respond to the Member stating the disposition and the rationale within thirty (30) days of receipt of the grievance. If the grievance is not resolved to the Member’s satisfaction, a second level of review may be requested within ten (10) days of notification of such disposition. Any such request will be reviewed by the Medical Director and responded to within seventy-two (72) hours of receipt. If the complaint or grievance involves a delay, modification, or denial of service related to a clinically emergent or urgent situation, the review will be expedited and a response provided in writing to the Member within three (3) days from receipt of the complaint or grievance. There is no requirement that the Member participate in Plan’s grievance process before requesting a review by the California Department of Managed Care (“Department”) in any case determined by the Department to be a case involving an imminent and serious threat to the health of the patient, including but not limited to severe pain, the potential loss of life, limb, or major bodily function, or in any other case where the Department determines that an earlier review is warranted. The criteria for determining emergent situations are whether the Member is assessed to be at imminent risk to seriously harm himself or another person, or is so impaired in judgment as to destroy property or be unable to care for his own basic needs. The criteria for determining urgent situations are whether the Member is assessed to be significantly distressed, and is experiencing a reduced level of functioning due to more than a moderate impairment resulting in an inability to function in key family/work roles. A Member, or the agent acting on behalf of the Member, may also request voluntary mediation with Plan prior to exercising the right to submit a grievance to the Department. The use of mediation services will not preclude the Member’s right to submit a grievance to the Department upon completion of the mediation. In order to initiate mediation, the Member, or the agent acting on behalf of the Member, and Plan will voluntarily agree to mediation. Expenses for the mediation will be borne equally by the parties. The Department will have no administrative or enforcement responsibilities in connection with the voluntary mediation process. Mediations will take place in San Diego, California unless otherwise determined by the parties. Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been canceled or not renewed because of his health status or requirement for services may request review by the Department. The California Department of Managed Health Care is responsible for regulating health care service plans. If a member has a grievance against the health plan, the member should first telephone the health plan at (▇-▇▇▇-▇▇▇-▇▇▇▇) and use the health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to the member. If a member needs help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the health plan, or a grievance that has remained unresolved for more than 30 days, the member may call the department for assistance. The member may also be eligible for an Independent Medical Review (IMR). If the member is eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (▇-▇▇▇-▇▇▇-▇▇▇▇) and a TDD line (▇-▇▇▇-▇▇▇-▇▇▇▇) for the hearing and speech impaired. The department’s Internet website ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇.▇▇.▇▇▇ has complaint forms, IMR application forms and instructions online. Plan’s grievance process and the department’s complaint review process are in addition to any other dispute resolution procedures that may be available to the member, and the member’s failure to use these processes does not preclude the member’s use of any other remedy provided by law.

COMPLAINT AND GRIEVANCE PROCEDURE. Members are entitled to present complaints and grievances involving Benefits, Plan and EAP Providers to Plan, and Plan is obliged to seek to resolve such complaints and grievances. Plan has established a procedure for processing and resolving Member complaints and grievances. A copy of this procedure, and the form to be used to file a complaint or grievance, are available from Plan and from all EAP Providers and EAP Provider locations. A grievance is a written or oral expression of dissatisfaction regarding Plan and/or an EAP Provider, including quality of care concerns, and includes a complaint, dispute, request for reconsideration reconsideration, or appeal made by a Member you or the Member’s your representative. A complaint is the same as a grievance. There is no discrimination by Plan against a Member for filing a grievance. Members You are entitled to present complaints and grievancesgrievances within one year of the occurrence. Plan is obliged to seek to resolve such complaints and grievances in a timely fashion. Members may file a grievance up to 365 calendar days following an incident or action that is the subject of the member’s dissatisfaction. Plan has established a procedure for processing and resolving Member your complaints and grievances. Should a Member you desire to register a complaint or grievance with Plan concerning Benefits, he/she you can either call Plan at the toll-free telephone number ▇-▇▇▇-▇▇▇-▇▇▇▇, or access Plan’s website at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ to report either download the complaint or grievance, form or to fill it out online. To request a copy of Plan’s Complaint Formcomplaint form, or write directly to Plan at ▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇. The telephone call or letter should be addressed to the Director, Clinical Quality Improvement. Plan will acknowledge each complaint and grievance within five (5) days of receipt. The Director, Clinical Quality Improvement, Improvement will receive and investigate all Member complaints and grievances. The Director, Clinical Quality Improvement, Improvement will respond to the Member you stating the disposition and the rationale within thirty (30) days of receipt of the grievance. If the grievance is not resolved to the Member’s your satisfaction, a second level of review may be requested within ten (10) days of notification of such disposition. Any such request will be reviewed by the Medical Director and responded to within seventy-two (72) hours of receipt. Linguistic and cultural needs will be addressed by translation of grievance forms and procedures into languages other than English. Using TTY lines and varying the means by which an Enrollee may submit a grievance, including verbally to Plan’s staff (bi-lingual capability), on website (Spanish and English), verbally by provider (multi-language capability), or interpreter. This allows Enrollees to submit grievances in a linguistically appropriate manner. When an Enrollee is seen with the aid of an interpreter, the interpreter or counselor reading this statement will explain the information that is normally provided in a written format. If you have a complaint or grievance about the services you have received, or will receive in the future, you may notify your counselor (or interpreter), who will supply them with a grievance form and a description of the process. If you wish to submit the grievance through your counselor or interpreter, you may do so. Visually impaired clients may phone the Director of Quality Improvement directly at 1-800- 342-8111. The Director, Quality Improvement, will describe the grievance procedure and take the grievance information. In this case, the appropriate letters would be sent, and the client contacted by telephone so that the letter can be read. Hearing impaired clients may file a grievance using the telephone number ▇▇▇-▇▇▇-▇▇▇▇ to contact Plan. If the complaint or grievance involves a delay, modification, or denial of service related to a clinically emergent or urgent situation, the review will be expedited and a response provided in writing to the Member you within three (3) days from receipt of the complaint or grievance. There is no requirement that the Member you participate in Plan’s grievance process before requesting a review by the California Department of Managed Care (“Department”) in any the case determined by the Department to be a case involving of an imminent and serious threat to the health of the patient, including but not limited to severe pain, the potential loss of life, limb, urgent or major bodily function, or in any other case where the Department determines that an earlier review is warrantedemergent grievance. The criteria for determining emergent situations are whether the Member is you are assessed to be at imminent risk to seriously harm himself yourself or another person, or is are so impaired in judgment as to destroy property or be unable to care for his your own basic needs. The criteria for determining urgent situations are whether the Member is you are assessed to be significantly distressed, and is are in any medical danger due to the level of the problem, or are experiencing a reduced level of functioning due to more than a moderate impairment resulting in an inability to function in key family/work roles. A MemberYou, or the agent acting on behalf of the Memberyour behalf, may also request voluntary mediation with Plan prior to exercising the right to submit a grievance to the Department. The use of mediation services will not preclude the Member’s your right to submit a grievance to the Department upon completion of the mediation. In order to initiate mediation, the Memberyou, or the agent acting on behalf of the Memberyour behalf, and Plan will voluntarily agree to mediation. Expenses for the mediation will be borne equally by the parties. The Department will have no administrative or enforcement responsibilities in connection with the voluntary mediation process. Mediations will take place in San Diego, California unless otherwise determined by the parties. Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been canceled or not renewed because of his health status or requirement for services may request review by the Department. The California Department of Managed Health Care is responsible for regulating health care service plans. If a member has you have a grievance against the your health plan, the member you should first telephone the your health plan at (▇-▇▇▇-▇▇▇-▇▇▇▇) and use the your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to the memberyou. If a member needs you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the health your plan, or a grievance that has remained unresolved for more than 30 days, the member you may call the department for assistance. The member You may also be eligible for an Independent Medical Review (IMR). If the member is you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, nature and payment disputes for emergency or urgent medical services. The department also has a toll-toll- free telephone number (▇-▇▇▇-▇▇▇-▇▇▇▇) and a TDD line (▇-▇▇▇-▇▇▇-▇▇▇▇) for the hearing and speech impaired. The department’s Internet website ▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇.▇▇.▇▇▇ has complaint forms, IMR application forms and instructions online. Plan’s grievance process and the departmentDepartment’s complaint review process are in addition to any other dispute resolution procedures that may be available to the memberyou, and the member’s your failure to use these processes does not preclude the member’s your use of any other remedy provided by law.