Common use of Grievance Process Clause in Contracts

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Subscribers may contact the Plan at the telephone number as noted in this Evidence of Coverage. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Repre- sentative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of Coverage. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber may also submit the grievance online by visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) calendar days. Grievances are re- solved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.

Grievance Process. Blue Shield of California has established a grievance procedure for re- ceivingreceiving, resolving and tracking Subscriber’s grievances with Blue Shield of CaliforniaSub- scribers’ grievances. For all Services other than Mental Health Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the Dental Customer Service Department by telephone, letter, letter or online to request a review of an initial determination concerning a claim or Serviceservice. Subscribers may contact the Plan Dental Customer Service Department at the telephone tele- phone number as noted in this Evidence of Coveragebelow. If the telephone inquiry to the Dental Customer Service Department does not resolve the question or issue to the Subscriber's satisfaction’s satis- faction, the Subscriber may request a grievance at that time, which the Dental Customer Service Repre- sentative Representa- tive will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of Coverage. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber may also submit the grievance online by visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) calendar days. Grievances are re- solved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's ’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Griev- ance Form". The Subscriber may request this Form form from the MHSA's Custom- er Dental Customer Service Department. The MHSA's If the Sub- xxxxxxx wishes, the Dental Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do sogrievance form. Completed grievance forms must be mailed to the MHSA a Dental Plan Ad- ministrator at the address provided below. The Subscriber Sub- xxxxxxx may also submit the grievance to the MHSA Dental Customer Service Department online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Dental Plan Administrator P. O. Box 719002 San Diego000 Xxxxxx Xxxxxx, CA 92171-9002 The MHSA 00xx Xxxxx Xxx Xxxxxxxxx, XX 00000 A Dental Plan Administrator will acknowledge receipt of a written grievance within five (5) 5 calendar days. Grievances Griev- ances are resolved within thirty (30) 30 days. The grievance system allows Subscribers to file grievances for at least griev- ances within 180 days following any incident or action that is the subject of the Subscriber's ’s dissatisfaction. See the previous Customer Service section for information informa- tion on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health Subscribers, a designated representative, or a provider on behalf of the Subscriber, Members may contact the Customer Service Department Blue Shield Member Services De- partment by telephone, letter, letter or online on-line to request a review of an initial determination concerning a claim or Serviceservice. Subscribers Mem- bers may contact the Plan at the telephone number as noted in on the last page of this Evidence of Coveragebooklet. If the telephone inquiry to Customer Service Member Services does not resolve the question or issue to the Subscriber's Member’s satisfaction, the Subscriber Member may request a grievance at that time, which the Customer Service Repre- sentative Member Services Representative will initiate on the Subscriber's Member’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber Member may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber Member may request this Form from Customer Service Member Services. The completed form should be submitted to Member Services at the address as noted in on the last page of this Evidence of Coveragebooklet. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber Member may also submit the grievance online by visit- ing visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) 5 calendar days. Grievances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers Members to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's Member’s dissatisfaction. See the previous Customer Service section following paragraph for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Note: Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diegohas established a procedure for our Members to request an expedited decision. A Mem- ber, CA 92171-9002 The MHSA will acknowledge Physician, or representative of a Member may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Member, or when the Member is experiencing severe pain. Blue Shield shall make a decision and notify the Member and Physician within 72 hours following the receipt of a grievance within five (5) calendar daysthe request. Grievances are resolved within thirty (30) daysAn ex- pedited decision may involve admissions, continued stay, or other healthcare services. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on If you would like additional infor- mation regarding the expedited decision process. If the grievance involves , or if you believe your particular situation qualifies for an MHSA Non-Participating Pro- viderexpedited decision, the Subscriber should please contact the appropriate Blue Shield of California Customer Service California’s Member Services Department as noted at the number provided on the last page of this booklet. External Independent Medical Review Note: If your grievance involves employer’s health plan is governed by the Em- ployee Retirement Income Security Act (“ERISA”), you may have the right to bring a civil action under Section 502(a) of ERISA if all required reviews of your claim or services for which cov- erage was denied by have been com- pleted and your claim has not been approved. Definitions American Specialty Health Plans of California, Inc. (ASH Plans) - ASH Plans is a licensed, specialized health care Ser- vice plan that has entered into an agreement with Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paiddelivery of chiropractic Ser- vices. This external review process is in addition to any other pro- cedures or remedies available to you Neuromusculo-skeletal Disorders – conditions with associ- ated signs and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan symptoms related to the medical necessity nervous, muscular, and/or skeletal systems. Neuromusculo-skeletal Disorders are conditions typically categorized as structural, degenera- tive or inflammatory disorders, or biomechanical dysfunction of a pro- posed service or treatmentthe joints of the body and/or related components of the motor unit (muscles, coverage decisions for treatments that are experimental or investigational in nature tendons, fascia, nerves, liga- ments/capsules, discs, and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000synovial structures) and related to neurological manifestations or conditions. Participating Provider – a TDD line (1-877-688- 9891) for the hearing and speech impairedParticipating Chiropractor or other licensed health care provider under contract with ASH Plans to provide Covered Services to Members. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Supplement C — Additional Infertility Benefits Summary of Benefits Member Maximum Lifetime Bene- fits Maximum Blue Shield Payment Covered Infertility Benefits up to the lifetime maximum None Covered Infertility Benefits Blue Shield Payment Covered Infertility Benefits up to the lifetime Benefit maximums as described in this Supple- ment 50% of California should cancel the allowable amount Introduction In addition to the Benefits listed in your Evidence of Cover- age and Disclosure Form, your Plan provides coverage for additional Infertility treatment provided to a Subscriber, spouse or refuse Domestic Partner covered hereunder as described herein. For the purpose of this Benefit, Infertility means the Member must actively be trying to renew the enrollment for you conceive and has, with respect to a Subscriber, spouse or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.Domestic Partner covered hereunder:

Grievance Process. Blue Shield has established a grievance procedure for receiving, resolving and tracking Members’ grievances with Blue Shield. mitted or required by law. A STATEMENT DESCRIBING BLUE SHIELD'S POLICIES AND PROCEDURES FOR PRESERV- ING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FUR- NISHED TO YOU UPON REQUEST. Blue Shield’s “Notice of Privacy Practices” can be obtained either by calling Customer Service at the number listed in the back of this EOC, or by access- ing Blue Shield’s internet site at xxx.xxxxxxxxxxxx.xxx and printing a copy. Members who are concerned that Blue Shield may have violated their privacy rights, or who disagree with a decision Blue Shield made about access to their individually identifiable personal information, may contact Blue Shield at: Correspondence Address: Blue Shield of California has established a procedure for re- ceivingPrivacy Office P.O. Box 272540 Chico, resolving and tracking Subscriber’s grievances with CA 95927-2540 Access to Information Blue Shield may need information from medical providers, from other carriers or other entities, or from the Member, in order to administer the Benefits and eligibility provisions of Californiathis Contract. For all By en- rolling in this health plan, each Member agrees that Medical Services other than Mental Health SubscribersThe Member, a designated representative, or a provider on behalf of the SubscriberMember, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination determina- tion concerning a claim or Serviceservice. Subscribers Members may contact the Plan Blue Shield at the telephone number as noted in on the back page of this Evidence of CoverageEOC. If the telephone inquiry in- quiry to Customer Service does not resolve the question ques- tion or issue to the Subscriber's Member’s satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Repre- sentative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of Coverage. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber may also submit the grievance online by visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) calendar days. Grievances are re- solved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber Mem- ber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's Member’s behalf. The SubscriberMember, a designated representative, or a provider on behalf of the Subscriber, Member may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber Member may request this Form from the MHSA's Custom- er Service DepartmentCustomer Service. The MHSA's completed form should be submitted to Customer Service staff will assist the Subscriber in the completing the Grievance FormAppeals and Grievance, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided belowP.O. Box 5588, El Dorado Hills, CA 95762-0011. The Subscriber Member may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxxour web site at xxx.xxxxxxxxxxxx.xxx. 0For all grievances except denial of coverage for a Non-000-000-0000 Formulary Drug: Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge acknowl- edge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) 30 days. Members can request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Member, or when the Member is experiencing severe pain. Blue Shield shall make a decision and notify the Member and Physician as soon as possible to accommodate the Member’s condition not to exceed 72 hours follow- ing the receipt of the request. An expedited decision may involve admissions, continued stay, or other health care services. For additional information re- xxxxxxx the expedited decision process, or to request an expedited decision be made for a particular issue, please contact Customer Service. For grievances due to denial of coverage for a Non-Formulary Drug: If your Employer selected the optional Outpatient Prescription Drug Benefits Supplement as a Benefit and Blue Shield denies an exception request for coverage of a Non-Formulary Drug, the Member, representative, or the Provider may submit a grievance requesting an external ex- ception request review. Blue Shield will ensure a de- cision within 72 hours in routine circumstances or 24 hours in exigent circumstances. For additional infor- mation, please contact Customer Service. For all grievances: The grievance system allows Subscribers to file grievances for at least within 180 days following fol- lowing any incident or action that is the subject of the Subscriber's Member’s dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health SubscribersMembers, a designated representative, or a provider on behalf of the SubscriberMember, may contact the Customer Dental Member Service Department De- partment by telephone, letter, letter or online to request a review of an initial determination concerning a claim or Serviceservice. Subscribers Mem- bers may contact the Plan Dental Member Service Department at the telephone number as noted in this Evidence of Coveragebelow. If the telephone inquiry to Customer the Dental Member Service Department does not resolve the question or issue to the Subscriber's Member’s satisfaction, the Subscriber Member may request a grievance at that time, which the Customer Dental Member Service Repre- sentative Representative will initiate on the Subscriber's Member’s behalf. The SubscriberMember, a designated representative, or a provider on behalf be- half of the Subscriber Member, may also initiate a grievance by submitting submit- ting a letter or a completed "“Grievance Form"”. The Subscriber Member may request this Form from Customer the Dental Member Service De- partment. If the Member wishes, the Dental Member Service staff will assist in completing the grievance form. Completed grievance forms must be mailed to a contracted Dental Plan Administrator at the address as noted in this Evidence of Coverageprovided below. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber Member may also submit the grievance to the Dental Member Service Department online by visit- ing our web site at visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Dental Plan Administrator 000 Xxxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxxxxxxx, XX 00000 A contracted Dental Plan Administrator will acknowledge receipt re- ceipt of a written grievance within five (5) 5 calendar days. Grievances Griev- ances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers Members to file grievances for at least 180 days following any incident or action that is the subject sub- ject of the Subscriber's Member’s dissatisfaction. See the previous Customer Member Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Serviceproc- ess. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible respon- sible for regulating health care service plans. If you have a grievance against your health planPlan, you should first telephone your health plan Plan at 0-000-000-0000 the number listed on the last pages of this booklet and use your health planPlan’s grievance process before contacting the De- partmentDepartment. Utilizing this grievance procedure does not prohib- it prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving in- volving an emer- gencyemergency, a grievance that has not been satisfactorily satisfacto- rily resolved by your health planPlan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tanceassistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide pro- vide an impartial review of medical decisions made by a health plan related to the medical necessity of a pro- posed proposed service or treatment, coverage decisions for treatments that are experimental experi- mental or investigational in nature nature, and pay- ment payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (10-877000-688- 9891000-0000) for the hearing and speech impaired. The Depart- mentDepartment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms forms, and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefitsBene- fits, you or your Dependents may request a review by the Department De- partment of Managed Health Care Director.

Grievance Process. Blue Shield has established a grievance procedure for receiving, resolving and tracking Members’ grievances with Blue Shield. mitted or required by law. A STATEMENT DESCRIBING BLUE SHIELD'S POLICIES AND PROCEDURES FOR PRESERV- ING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FUR- NISHED TO YOU UPON REQUEST. Blue Shield’s “Notice of Privacy Practices” can be obtained either by calling Customer Service at the number listed in the back of this EOC, or by access- ing Blue Shield’s internet site at xxx.xxxxxxxxxxxx.xxx and printing a copy. Members who are concerned that Blue Shield may have violated their privacy rights, or who disagree with a decision Blue Shield made about access to their individually identifiable personal information, may contact Blue Shield at: Correspondence Address: Blue Shield of California has established a procedure for re- ceivingPrivacy Xxxxxx X.X. Xxx 000000 Xxxxx, resolving and tracking Subscriber’s grievances with XX 00000-0000 Access to Information Blue Shield may need information from medical providers, from other carriers or other entities, or from the Member, in order to administer the Benefits and eligibility provisions of Californiathis Contract. For all By en- rolling in this health plan, each Member agrees that Medical Services other than Mental Health SubscribersThe Member, a designated representative, or a provider on behalf of the SubscriberMember, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination determina- tion concerning a claim or Serviceservice. Subscribers Members may contact the Plan Blue Shield at the telephone number as noted in on the back page of this Evidence of CoverageEOC. If the telephone inquiry in- quiry to Customer Service does not resolve the question ques- tion or issue to the Subscriber's Member’s satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Repre- sentative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of Coverage. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber may also submit the grievance online by visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) calendar days. Grievances are re- solved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber Mem- ber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's Member’s behalf. The SubscriberMember, a designated representative, or a provider on behalf of the Subscriber, Member may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber Member may request this Form from the MHSA's Custom- er Service DepartmentCustomer Service. The MHSA's completed form should be submitted to Customer Service staff will assist the Subscriber in the completing the Grievance FormAppeals and Grievance, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided belowX.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Subscriber Member may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxxour web site at xxx.xxxxxxxxxxxx.xxx. 0For all grievances except denial of coverage for a Non-000-000-0000 Formulary Drug: Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge acknowl- edge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) 30 days. Members can request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Member, or when the Member is experiencing severe pain. Blue Shield shall make a decision and notify the Member and Physician as soon as possible to accommodate the Member’s condition not to exceed 72 hours follow- ing the receipt of the request. An expedited decision may involve admissions, continued stay, or other health care services. For additional information re- xxxxxxx the expedited decision process, or to request an expedited decision be made for a particular issue, please contact Customer Service. For grievances due to denial of coverage for a Non-Formulary Drug: If your Employer selected the optional Outpatient Prescription Drug Benefits Supplement as a Benefit and Blue Shield denies an exception request for coverage of a Non-Formulary Drug, the Member, representative, or the Provider may submit a grievance requesting an external ex- ception request review. Blue Shield will ensure a de- cision within 72 hours in routine circumstances or 24 hours in exigent circumstances. For additional infor- mation, please contact Customer Service. For all grievances: The grievance system allows Subscribers to file grievances for at least within 180 days following fol- lowing any incident or action that is the subject of the Subscriber's Member’s dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health SubscribersMembers, a designated representative, or a provider on behalf of the SubscriberMember, may contact the Customer Service Department Dental Member Services De- partment by telephone, letter, or online on-line to request a review of an initial determination concerning a claim or Service. Subscribers Mem- bers may contact the Plan Dental Member Services Department at the telephone number as noted in this Evidence of Coveragebelow. If the telephone inquiry to Customer Service the Dental Member Services Department does not resolve the question or issue to the SubscriberMember's satisfaction, the Subscriber Member may request a grievance at that time, which the Customer Service Repre- sentative Dental Member Services Representative will initiate on the SubscriberMember's behalf. The SubscriberMember, a designated representative, or a provider on behalf be- half of the Subscriber Member, may also initiate a grievance by submitting submit- ting a letter or a completed "Grievance Form". The Subscriber Member may request this Form from Customer Service the Dental member Services De- partment. If the Member wishes, the Dental Member Services staff will assist in completing the grievance form. Completed grievance forms must be mailed to a contracted Dental Plan Administrator at the address as noted in this Evidence of Coverageprovided below. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber Member may also submit the grievance online to the Dental Member Services Department on-line by visit- ing our web site at visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Dental Plan Administrator 000 Xxxxxx Xxxxxx, 00xx. Floor San Francisco, CA 94105 A contracted Dental Plan Administrator will acknowledge receipt re- ceipt of a written grievance within five (5) calendar days. Grievances are re- solved resolved within thirty (30) days). The grievance system allows Subscribers Members to file grievances for at least 180 days following any incident or action that is the subject sub- ject of the Subscriberenrollee's dissatisfaction. See the previous Customer Service Member Services section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible respon- sible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan Plan at 0-000-000-0000 and use your health planPlan’s grievance process before contacting the De- partmentDepartment. Utilizing this grievance procedure does not prohib- it prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gencyemergency, a grievance that has not been satisfactorily resolved by your health planPlan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tanceassistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide pro- vide an impartial review of medical decisions made by a health plan Plan related to the medical necessity of a pro- posed proposed service or treatment, coverage decisions for treatments that are experimental experi- mental or investigational in nature and pay- ment payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 0-000-XXX-0000) and a TDD line (10-877000-688- 9891000-0000) for the hearing and speech impaired. The Depart- mentDepartment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefitsbene- fits, you or your Dependents may request a review by the Department De- partment of Managed Health Care Director.

Grievance Process. Blue Shield of California has established a procedure grievance proce- dure for re- ceivingreceiving, resolving and tracking Subscriber’s grievances Subscribers’ griev- ances with Blue Shield of California. For all Services other than Mental Health FOR ALL SERVICES OTHER THAN MENTAL HEALTH Subscribers, a designated representative, or a provider on behalf of the Subscriber, Subscriber may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Serviceservice. Subscribers may contact the Plan at the telephone number as noted in on the back page of this Evidence of Coveragebooklet. If the telephone inquiry in- quiry to Customer Service does not resolve the question or issue to the Subscriber's ’s satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Repre- sentative Representative will initiate on the Subscriber's ’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of CoverageService. The com- pleted Form completed form should be submitted to: Blue Shield of California to Customer Service Ser- vice Appeals and Grievance Grievance, P.O. Box 5588 5588, El Dorado Hills, CA 95762-0011 0011. The Subscriber may also submit the grievance online by visit- ing visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) 5 calendar days. Grievances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's ’s dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services FOR ALL MENTAL HEALTH SERVICES Subscribers, a designated representative, or a provider on behalf of the Subscriber, Subscriber may contact the MHSA by tele- phone, letter, or online to request a review of an initial determination de- termination concerning a claim or Serviceservice. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone telephone inquiry to the MHSA's ’s Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfactionSub- xxxxxxx’x satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's ’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, Subscriber may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber may request this Form from the MHSA's Custom- er ’s Cus- tomer Service Department. The If the Subscriber wishes, the MHSA's ’s Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.Administrator

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the Customer Service Department by telephone, letter, or online to request a review of an initial determination concerning a claim or Service. Subscribers may contact the Plan at the telephone number as noted in this Evidence of Coverage. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Repre- sentative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of Coverage. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber may also submit the grievance online by visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) calendar days. Grievances are re- solved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.Administrator

Grievance Process. Blue Shield of California has established a procedure grievance pro- cedure for re- ceivingreceiving, resolving and tracking Subscriber’s Subscribers’ grievances with Blue Shield of California. For all Services other than Mental Health FOR ALL SERVICES OTHER THAN MENTAL HEALTH Subscribers, a designated representative, or a provider on behalf of the Subscriber, Subscriber may contact the Customer Service Department by telephone, letter, or online to request a review re- view of an initial determination concerning a claim or Serviceser- vice. Subscribers may contact the Plan at the telephone number as noted in on the back page of this Evidence of Coveragebooklet. If the telephone inquiry to Customer Service does not resolve the question or issue to the Subscriber's ’s satisfaction, the Subscriber Sub- xxxxxxx may request a grievance at that time, which the Customer Cus- tomer Service Repre- sentative Representative will initiate on the Subscriber's Subscrib- er’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber may request this Form from Customer Service at the address as noted in this Evidence of CoverageService. The com- pleted Form completed form should be submitted to: Blue Shield of California to Customer Service Ser- vice Appeals and Grievance P.O. Box 5588 El Dorado HillsGrievance, CA 95762X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0011 0000. The Subscriber may also submit the grievance online by visit- ing visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) 5 calendar days. Grievances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's ’s dissatisfaction. See the previous pre- vious Customer Service section for information on the expedited ex- pedited decision process. For all Mental Health Services FOR ALL MENTAL HEALTH SERVICES Subscribers, a designated representative, or a provider on behalf of the Subscriber, Subscriber may contact the MHSA by tele- phone, letter, or online to request a review of an initial determination de- termination concerning a claim or Serviceservice. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone telephone inquiry to the MHSA's ’s Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction’s satisfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative Repre- sentative will initiate on the Subscriber's ’s behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, Subscriber may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber may request this Form from the MHSA's Custom- er ’s Cus- tomer Service Department. The If the Subscriber wishes, the MHSA's ’s Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.Administrator

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health Subscribers, a designated representative, or a provider on behalf of the Subscriber, Members may contact the Customer Service Department Blue Shield Member Services De- partment by telephone, letter, letter or online on-line to request a review of an initial determination concerning a claim or Serviceservice. Subscribers Mem- bers may contact the Plan at the telephone number as noted in this the back of your Evidence of CoverageCoverage and Disclosure Form. If the telephone inquiry to Customer Service Member Services does not resolve the question or issue to the Subscriber's Member’s satisfaction, the Subscriber Mem- ber may request a grievance at that time, which the Customer Service Repre- sentative Member Services Representative will initiate on the Subscriber's Member’s behalf. Note: You may have the right to receive continued coverage pending the outcome of your grievance. To request continued coverage during your grievance, contact Member Services at the telephone number on your identification card. The Subscriber, a designated representative, or a provider on behalf of the Subscriber Member may also initiate a grievance by submitting a letter or a completed "“Grievance Form"”. The Subscriber Member may request this Form from Customer Service Member Services. The completed form should be submitted to Member Services at the address as noted in this the back of your Evidence of CoverageCoverage and Dis- closure Form. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber Member may also submit the grievance online by visit- ing visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within five (5) 5 calendar days. Grievances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers Members to file grievances for at least 180 days following any incident or action that is the subject sub- ject of the Subscriber's Member’s dissatisfaction. See the previous Customer Service section following para- graph for information on the expedited decision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Note: Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diegohas established a procedure for our Members to request an expedited decision. A Mem- ber, CA 92171-9002 The MHSA will acknowledge Physician, or representative of a Member may request an expedited decision when the routine decision making process might seriously jeopardize the life or health of a Member, or when the Member is experiencing severe pain. Blue Shield shall make a decision and notify the Member and Physician within 72 hours following the receipt of a grievance within five (5) calendar daysthe request. Grievances are resolved within thirty (30) daysAn ex- pedited decision may involve admissions, continued stay, or other healthcare services. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on If you would like additional infor- mation regarding the expedited decision process, or if you believe your particular situation qualifies for an expedited decision, please contact Blue Shield of California’s Member Services Department at the number provided in the back of your Evidence of Coverage and Disclosure Form. Note: If your Employer’s health plan is governed by the grievance involves Em- ployee Retirement Income Security Act (“ERISA”), you may have the right to bring a civil action under Section 502(a) of ERISA if all required reviews of your claim have been com- pleted and your claim has not been approved. Definitions American Specialty Health Plans of California, Inc. (ASH Plans) – ASH Plans is a licensed, specialized health care ser- vice plan that has entered into an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate agreement with Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service delivery of acupuncture and chiropractic Services. Nausea – an unpleasant sensation in the abdominal region associated with the desire to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies vomit that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made appropriately treated by a health plan Participating acupuncturist in accordance with professionally recognized standards of practice and includes adult post-operative Nausea and vomiting, and Nausea of pregnancy. Neuromusculo-skeletal Disorders – conditions with associ- ated signs and symptoms related to the medical necessity nervous, muscular, and/or skeletal systems. Neuromusculo-skeletal Disorders are conditions typically categorized as structural, degenerative or inflammatory disorders, or biomechanical dysfunction of a pro- posed service or treatmentthe joints of the body and/or related components of the motor unit (muscles, coverage decisions for treatments that are experimental or investigational in nature tendons, fascia, nerves, ligaments/capsules, discs, and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000synovial structures) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel related to neurological manifesta- tions or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Directorconditions.

Grievance Process. Blue Shield of California has established a procedure for re- ceiving, resolving and tracking Subscriber’s grievances with Blue Shield of California. For all Services other than Mental Health SubscribersMembers, a designated representative, or a provider on behalf of the SubscriberMember, may contact the Customer Dental Member Service Department De- partment by telephone, letter, letter or online to request a review of an initial determination concerning a claim or Serviceservice. Subscribers Mem- bers may contact the Plan Dental Member Service Department at the telephone number as noted in this Evidence of Coveragebelow. If the telephone inquiry in- quiry to Customer the Dental Member Service Department does not resolve re- solve the question or issue to the Subscriber's Member’s satisfaction, the Subscriber Member may request a grievance at that time, which the Customer Den- tal Member Service Repre- sentative Representative will initiate on the Subscriber's Mem- ber’s behalf. Note: You may have the right to receive continued coverage pending the outcome of your grievance. To request continued coverage during your grievance, contact Dental Member Ser- vices at the telephone number listed below. The SubscriberMember, a designated representative, or a provider on behalf of the Subscriber Member, may also initiate a grievance by submitting sub- mitting a letter or a completed "“Grievance Form"”. The Subscriber Mem- ber may request this Form from Customer the Dental Member Service Department. If the Member wishes, the Dental Member Ser- vice staff will assist in completing the grievance form. Com- pleted grievance forms must be mailed to a contracted Dental Plan Administrator at the address as noted in this Evidence of Coverageprovided below. The com- pleted Form should be submitted to: Blue Shield of California Customer Service Appeals and Grievance P.O. Box 5588 El Dorado Hills, CA 95762-0011 The Subscriber Member may also submit the grievance to the Dental Member Service Department online by visit- ing our web site at visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Dental Plan Administrator 000 Xxxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxxxxxxx, XX 00000 A contracted Dental Plan Administrator will acknowledge receipt of a written grievance within five (5) 5 calendar days. Grievances Griev- ances are re- solved resolved within thirty (30) 30 days. The grievance system allows Subscribers Members to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's Member’s dissatisfaction. See the previous Customer Member Service section for information on the expedited decision de- cision process. For all Mental Health Services Subscribers, a designated representative, or a provider on behalf of the Subscriber, may contact the MHSA by tele- phone, letter, or online to request an initial determination concerning a claim or Service. Subscribers may contact the MHSA at the telephone number as noted below. If the tele- phone inquiry to the MHSA's Customer Service Department does not resolve the question or issue to the Subscriber's sat- isfaction, the Subscriber may request a grievance at that time, which the Customer Service Representative will initiate on the Subscriber's behalf. The Subscriber, a designated representative, or a provider on behalf of the Subscriber, may also initiate a grievance by submitting a letter or a completed "Grievance Form". The Subscriber may request this Form from the MHSA's Custom- er Service Department. The MHSA's Customer Service staff will assist the Subscriber in the completing the Grievance Form, if the Subscriber wishes them to do so. Completed grievance forms must be mailed to the MHSA at the address provided below. The Subscriber may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield of California Mental Health Service Administrator P. O. Box 719002 San Diego, CA 92171-9002 The MHSA will acknowledge receipt of a grievance within five (5) calendar days. Grievances are resolved within thirty (30) days. The grievance system allows Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Subscriber's dissatisfaction. See the previous Customer Service section for information on the expedited decision process. If the grievance involves an MHSA Non-Participating Pro- vider, the Subscriber should contact the appropriate Blue Shield of California Customer Service Department as noted on the last page of this booklet. External Independent Medical Review If your grievance involves a claim or services for which cov- erage was denied by Blue Shield of California or by a con- tracting provider in whole or in part on the grounds that the service is not Medically Necessary or is experi- mental/investigational (including the external review availa- ble under the Xxxxxxxx-Xxxxxxx Experimental Treatment Act of 1996), you may choose to make a request to the De- partment of Managed Health Care to have the matter submit- xxx to an independent agency for external review in accord- ance with California law. You normally must first submit a grievance to Blue Shield of California and wait for at least 30 days before you request external review; however, if your matter would qualify for an expedited decision as described above or involves a determi- nation that the requested service is experi- mental/investigational, you may immediately request an ex- ternal review following receipt of notice of denial. You may initiate this review by completing an application for external review, a copy of which can be obtained by contact- ing Customer Service. The Department of Managed Health Care will review the application and, if the request qualifies for external review, will select an external review agency and have your records submitted to a qualified specialist for an independent determination of whether the care is Medically Necessary. You may choose to submit additional records to the external review agency for review. There is no cost to you for this external review. You and your physician will receive copies of the opinions of the external review agency. The decision of the external re- view agency is binding on Blue Shield; if the external re- viewer determines that the service is Medically Necessary, Blue Shield will promptly arrange for the service to be pro- vided or the claim in dispute to be paid. This external review process is in addition to any other pro- cedures or remedies available to you and is completely volun- tary on your part; you are not obligated to request external review. However, failure to participate in external review may cause you to give up any statutory right to pursue legal action against Blue Shield of California regarding the disput- ed service. For more information regarding the external re- view process, or to request an application form, please con- tact Customer Service. Department of Managed Health Care Review The California Department of Managed Health Care is re- sponsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 0-000-000-0000 and use your health plan’s grievance process before contacting the De- partment. Utilizing this grievance procedure does not prohib- it any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emer- gency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assis- tance. You may also be eligible for an Independent Medical Review (IMR). If 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 pro- posed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and pay- ment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0- 000-XXX-0000) and a TDD line (1-877-688- 9891) for the hearing and speech impaired. The Depart- ment’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield of California should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of health or utilization of benefits, you or your Dependents may request a review by the Department of Managed Health Care Director.