Common use of Grievance Process Clause in Contracts

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member may contact the Member Services Department by telephone, letter or online to request a review of an initial determination concerning a claim or service. Members may contact the Plan at the telephone number as noted on the last page of this booklet. If the telephone inquiry to Member Ser- vices does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Member’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from Member Services. The completed form should be submitted to Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member may also submit the grievance online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s dissatisfaction. See the previous Member Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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

Grievance Process. Blue Shield of California has established a grievance proce- dure procedure for receiving, resolving and tracking MembersSub- scribers’ griev- ances with Blue Shield of Californiagrievances. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the Member Services Dental Customer Service Department by telephone, letter or online to request a review of an initial determination concerning a claim or service. Members Subscribers may contact the Plan Dental Customer Service Department at the telephone tele- phone number as noted on the last page of this bookletbelow. If the telephone inquiry to Member Ser- vices the Dental Customer Service Department does not resolve the question or issue to the MemberSubscriber’s satisfactionsatis- faction, the Member Subscriber may request a grievance at that time, which the Member Services Representative Dental Customer Service Representa- tive will initiate on the MemberSubscriber’s behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber, may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Griev- ance Form”. The Member Subscriber may request this form from Member Servicesthe Dental Customer Service Department. If the Sub- xxxxxxx wishes, the Dental Customer Service staff will assist in completing the grievance form. Completed grievance forms must be mailed to a Dental Plan Ad- ministrator at the address provided below. The completed form should be submitted to Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member Sub- xxxxxxx may also submit the grievance to the Dental Customer Service Department online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California Dental Plan Administrator 000 Xxxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxxxxxxx, XX 00000 A Dental Plan Administrator will acknowledge receipt of a written grievance within 5 calendar days. Grievances Griev- ances are resolved within 30 days. The grievance system allows Members Subscribers to file grievances for at least griev- ances within 180 days following any incident or action that is the subject of the MemberSubscriber’s dissatisfaction. See the previous Member Services Customer Service section for information informa- tion on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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.

Grievance Process. Blue Shield of California has established a grievance proce- dure procedure for receivingre- ceiving, resolving and tracking Members’ griev- ances Subscriber’s grievances with Blue Shield of California. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the Member Services Customer Service Department by telephone, letter letter, or online to request a review of an initial determination concerning a claim or serviceService. Members Subscribers may contact the Plan at the telephone number as noted on the last page in this Evidence of this bookletCoverage. If the telephone inquiry to Member Ser- vices Customer Service does not resolve the question or issue to the Member’s Subscriber's satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Representative Customer Service Repre- sentative will initiate on the Member’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from Member ServicesCustomer Service at the address as noted in this Evidence of Coverage. The completed form com- pleted Form should be submitted to Member Services to: Blue Shield of California Customer Service Appeals and GrievanceGrievance P.O. Box 5588 El Dorado Hills, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000CA 95762-0000. 0011 The Member Subscriber may also submit the grievance online by visiting visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within 5 five (5) calendar days. Grievances are resolved re- solved within 30 thirty (30) days. The grievance system allows Members Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Member’s Subscriber's dissatisfaction. See the previous Member Services Customer Service section for information on the expedited decision process. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the MHSA by telephonetele- phone, letter letter, or online to request a review of an initial determination concern- ing concerning a claim or serviceService. Members Subscribers may contact the MHSA at the telephone number as noted below. If the telephone in- quiry tele- phone inquiry to the MHSA’s Member Services 's Customer Service Department does not resolve the question or issue to the Member’s satisfactionSubscriber's sat- isfaction, the Member Subscriber may request a grievance at that time, which the Member Services Customer Service Representative will initiate on the Mem- ber’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber, may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from the MHSA’s Member Services 's Custom- er Service Department. If the Member wishes, the The MHSA’s Member Services 's Customer Service staff will assist the Subscriber in the completing the Griev- ance 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 Member 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 AdministratorAdministrator 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. 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. 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 proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Member, may contact the Dental Member Services Department De- partment by telephone, letter letter, or online on-line to request a review of an initial determination concerning a claim or serviceService. Members Mem- bers may contact the Plan Dental Member Services Department at the telephone number as noted on the last page of this bookletbelow. If the telephone inquiry to the Dental Member Ser- vices Services Department does not resolve the question or issue to the Member’s 's satisfaction, the Member may request a grievance at that time, which the Dental Member Services Representative will initiate on the Member’s 's behalf. The Member, a designated representative, or a provider on behalf be- half of the Member Member, may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member may request this form Form from Member Services. The completed form should be submitted to the Dental Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member may also submit the grievance online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s dissatisfaction. See the previous Member Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services DepartmentDepart- ment. If the Member wishes, the MHSA’s Dental Member Services staff will assist in completing the Griev- ance Formgrievance form. Completed grievance griev- ance forms must be mailed to the MHSA a contracted Dental Plan Admin- istrator at the address provided below. The Member may also submit the grievance to the MHSA online Dental Member Services Depart- ment on-line by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California Dental Plan Administrator 000 Xxxxxx Xxxxxx, 00xx Xxxxx Xxx Xxxxxxxxx, XX 00000 A Dental Plan Administrator will acknowledge receipt of a written grievance within 5 calendar days. Grievances are re- solved within 30 calendar days. The grievance system allows Members to file grievances within 180 days following any incident or action that is the sub- ject of the enrollee's dissatisfaction. See the previous Member The California Department of Managed Health Care is respon- sible 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 Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, 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 assistance. You may also be eligible for an independent medical review (IMR). If you are eligible for IMR, the IMR process will pro- vide an impartial review of medical decisions made by a health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are Experi- mental or Investigational in Nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0-000-000-0000) and a TDD line (0-000-000-0000) for the hearing and speech impaired. The Department’s internet website (xxxx://xxx.xxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of California Mental health or utilization of Ben- efits, you or your Dependents may request a review by the De- partment of Managed Health Service AdministratorCare Director.

Grievance Process. Blue Shield of California has established a grievance proce- dure procedure for receivingre- ceiving, resolving and tracking Members’ griev- ances Subscriber’s grievances with Blue Shield of California. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the Member Services Customer Service Department by telephone, letter letter, or online to request a review of an initial determination concerning a claim or serviceService. Members Subscribers may contact the Plan at the telephone number as noted on the last page in this Evidence of this bookletCoverage. If the telephone inquiry to Member Ser- vices Customer Service does not resolve the question or issue to the Member’s Subscriber's satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Representative Customer Service Repre- sentative will initiate on the Member’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from Member ServicesCustomer Service at the address as noted in this Evidence of Coverage. The completed form com- pleted Form should be submitted to Member Services to: Blue Shield of California Customer Service Appeals and GrievanceGrievance P.O. Box 5588 El Dorado Hills, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000CA 95762-0000. 0011 The Member Subscriber may also submit the grievance online by visiting visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within 5 five (5) calendar days. Grievances are resolved re- solved within 30 thirty (30) days. The grievance system allows Members Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Member’s Subscriber's dissatisfaction. See the previous Member Services Customer Service section for information on the expedited decision process. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the MHSA by telephonetele- phone, letter letter, or online to request a review of an initial determination concern- ing concerning a claim or serviceService. Members Subscribers may contact the MHSA at the telephone number as noted below. If the telephone in- quiry tele- phone inquiry to the MHSA’s Member Services 's Customer Service Department does not resolve the question or issue to the Member’s satisfactionSubscriber's sat- isfaction, the Member Subscriber may request a grievance at that time, which the Member Services Customer Service Representative will initiate on the Mem- ber’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber, may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from the MHSA’s Member Services 's Custom- er Service Department. If the Member wishes, the The MHSA’s Member Services 's Customer Service staff will assist the Subscriber in the completing the Griev- ance 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 Member 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 AdministratorAdministrator 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. 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. 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. 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- 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 proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Member, may contact the Dental Member Services Department De- partment by telephone, letter letter, or online on-line to request a review of an initial determination concerning a claim or serviceService. Members Mem- bers may contact the Plan Dental Member Services Department at the telephone number as noted on the last page of this bookletbelow. If the telephone inquiry to the Dental Member Ser- vices Services Department does not resolve the question or issue to the Member’s 's satisfaction, the Member Mem- ber may request a grievance at that time, which the Dental Member Services Representative will initiate on the Member’s 's behalf. The Member, a designated representative, or a provider on behalf of the Member Member, may also initiate a grievance by sub- mitting a letter or a completed “"Grievance Form”". The Member Mem- ber may request this form Form from the Dental Member ServicesServices Department. If the Member wishes, the Dental Member Ser- vices staff will assist in completing the grievance form. Com- pleted grievance forms must be mailed to a contracted Dental Plan Administrator at the address provided below. The completed form should be submitted to Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member Mem- ber may also submit the grievance online to the Dental Member Ser- vices Department on-line by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 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 5 calendar days. Grievances Griev- ances are resolved within 30 calendar days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s enrollee's dissatisfaction. See the previous Member Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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.

Grievance Process. Blue Shield of California has established a grievance proce- dure pro- cedure for receiving, resolving and tracking MembersSubscribers’ griev- ances grievances with Blue Shield of California. MembersFOR ALL SERVICES OTHER THAN MENTAL HEALTH Subscribers, a designated representative, or a provider on behalf of the Member Subscriber may contact the Member Services Customer Service Department by telephone, letter letter, or online to request a review re- view of an initial determination concerning a claim or serviceser- vice. Members Subscribers may contact the Plan at the telephone number as noted on the last back page of this booklet. If the telephone inquiry to Member Ser- vices Customer Service does not resolve the question or issue to the MemberSubscriber’s satisfaction, the Member Sub- xxxxxxx may request a grievance at that time, which the Member Services Cus- tomer Service Representative will initiate on the MemberSubscrib- er’s behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member Subscriber may request this form Form from Member ServicesCustomer Service. The completed form should be submitted to Member Services Customer Ser- vice Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member Subscriber may also submit the grievance online by visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the MemberSubscriber’s dissatisfaction. See the previous Member Services pre- vious Customer Service section for information on the expedited ex- pedited decision process. MembersFOR ALL MENTAL HEALTH SERVICES Subscribers, a designated representative, or a provider on behalf of the Member Subscriber may contact the MHSA by telephonetele- phone, letter letter, or online to request a review of an initial determination concern- ing de- termination concerning a claim or service. Members Subscribers may contact the MHSA at the telephone number as noted below. If the telephone in- quiry inquiry to the MHSA’s Member Services Customer Service Department does not resolve the question or issue to the MemberSubscriber’s satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Representative Customer Service Repre- sentative will initiate on the Mem- berSubscriber’s behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member Subscriber may request this form Form from the MHSA’s Member Services Cus- tomer Service Department. If the Member Subscriber wishes, the MHSA’s Member Services Customer Service staff will assist in completing the Griev- ance Grievance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Members may contact the Blue Shield Member Services Department De- partment by telephone, letter or online on-line to request a review of an initial determination concerning a claim or service. Members Mem- bers may contact the Plan at the telephone number as noted on the last page of this booklet. If the telephone inquiry to Member Ser- vices Services does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Member’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member may request this form Form from Member Services. The completed form should be submitted to Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000at the address as noted on the last page of this booklet. The Member may also submit the grievance online by visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s dissatisfaction. See the previous Member Services section following paragraph for information on the expedited decision process. MembersNote: Blue Shield of California has established a procedure for our Members to request an expedited decision. A Mem- ber, a designated representativePhysician, or representative of a provider on behalf 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 the Member request. An ex- pedited decision may contact the MHSA by telephoneinvolve admissions, letter continued stay, or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted belowother healthcare services. If you would like additional infor- mation regarding the telephone in- quiry to the MHSAexpedited decision process, or if you believe your particular situation qualifies for an expedited decision, please contact Blue Shield of California’s Member Services Department does at the number provided on the last page of this booklet. Note: If your 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 have been com- pleted and your claim has not resolve the question or issue been approved. In addition to the Member’s satisfactionBenefits listed in your Evidence of Cover- age and Disclosure Form, your Plan provides coverage for additional Infertility treatment provided to a Subscriber, spouse or Domestic Partner covered hereunder as described herein. For the purpose of this Benefit, Infertility means the Member may request must actively be trying to conceive and has, with respect to a grievance at that timeSubscriber, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, spouse or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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 AdministratorDomestic Partner covered hereunder:

Grievance Process. Blue Shield of California has established a grievance proce- dure procedure for receivingre- ceiving, resolving and tracking Members’ griev- ances Subscriber’s grievances with Blue Shield of California. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the Member Services Customer Service Department by telephone, letter letter, or online to request a review of an initial determination concerning a claim or serviceService. Members Subscribers may contact the Plan at the telephone number as noted on the last page in this Evidence of this bookletCoverage. If the telephone inquiry to Member Ser- vices Customer Service does not resolve the question or issue to the Member’s Subscriber's satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Representative Customer Service Repre- sentative will initiate on the Member’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from Member ServicesCustomer Service at the address as noted in this Evidence of Coverage. The completed form com- pleted Form should be submitted to Member Services to: Blue Shield of California Customer Service Appeals and GrievanceGrievance P.O. Box 5588 El Dorado Hills, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000CA 95762-0000. 0011 The Member Subscriber may also submit the grievance online by visiting visit- ing our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield of California will acknowledge receipt of a grievance within 5 five (5) calendar days. Grievances are resolved re- solved within 30 thirty (30) days. The grievance system allows Members Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the Member’s Subscriber's dissatisfaction. See the previous Member Services Customer Service section for information on the expedited decision process. MembersSubscribers, a designated representative, or a provider on behalf of the Member Subscriber, may contact the MHSA by telephonetele- phone, letter letter, or online to request a review of an initial determination concern- ing concerning a claim or serviceService. Members Subscribers may contact the MHSA at the telephone number as noted below. If the telephone in- quiry tele- phone inquiry to the MHSA’s Member Services 's Customer Service Department does not resolve the question or issue to the Member’s satisfactionSubscriber's sat- isfaction, the Member Subscriber may request a grievance at that time, which the Member Services Customer Service Representative will initiate on the Mem- ber’s Subscriber's behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber, may also initiate a grievance by sub- mitting submitting a letter or a completed “"Grievance Form”". The Member Subscriber may request this form Form from the MHSA’s Member Services 's Custom- er Service Department. If the Member wishes, the The MHSA’s Member Services 's Customer Service staff will assist the Subscriber in the completing the Griev- ance 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 Member 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

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking MembersSubscribers’ griev- ances with Blue Shield of California. MembersFOR ALL SERVICES OTHER THAN MENTAL HEALTH Subscribers, a designated representative, or a provider on behalf of the Member Subscriber may contact the Member Services Customer Service Department by telephone, letter letter, or online to request a review of an initial determination concerning a claim or service. Members Subscribers may contact the Plan at the telephone number as noted on the last back page of this booklet. If the telephone inquiry in- quiry to Member Ser- vices Customer Service does not resolve the question or issue to the MemberSubscriber’s satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Customer Service Representative will initiate on the MemberSubscriber’s behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member Subscriber may request this form Form from Member ServicesCustomer Service. The completed form should be submitted to Member Services Customer Ser- vice Appeals and Grievance, X.X. Xxx 0000P.O. Box 5588, Xx Xxxxxx XxxxxEl Dorado Hills, XX 00000CA 95762-00000011. The Member Subscriber may also submit the grievance online by visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members Subscribers to file grievances for at least 180 days following any incident or action that is the subject of the MemberSubscriber’s dissatisfaction. See the previous Member Services Customer Service section for information on the expedited decision process. MembersFOR ALL MENTAL HEALTH SERVICES Subscribers, a designated representative, or a provider on behalf of the Member Subscriber may contact the MHSA by telephonetele- phone, letter letter, or online to request a review of an initial determination concern- ing de- termination concerning a claim or service. Members Subscribers may contact the MHSA at the telephone number as noted below. If the telephone in- quiry inquiry to the MHSA’s Member Services Customer Service Department does not resolve the question or issue to the Member’s Sub- xxxxxxx’x satisfaction, the Member Subscriber may request a grievance at that time, which the Member Services Customer Service Representative will initiate on the Mem- berSubscriber’s behalf. The MemberSubscriber, a designated representative, or a provider on behalf of the Member Subscriber may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member Subscriber may request this form Form from the MHSA’s Member Services Cus- tomer Service Department. If the Member Subscriber wishes, the MHSA’s Member Services Customer Service staff will assist in completing the Griev- ance Grievance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Members may contact the Blue Shield Member Services Department De- partment by telephone, letter or online on-line to request a review of an initial determination concerning a claim or service. Members Mem- bers may contact the Plan at the telephone number as noted on in the last page back of this bookletyour Evidence of Coverage and Disclosure Form. If the telephone inquiry to Member Ser- vices Services does not resolve the question or issue to the Member’s satisfaction, the Member Mem- ber may request a grievance at that time, which the Member Services Representative will initiate on the 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 Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. The Member may request this form Form from Member Services. The completed form should be submitted to Member Services Appeals at the address as noted in the back of your Evidence of Coverage and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000Dis- closure Form. The Member may also submit the grievance online by visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject sub- ject of the Member’s dissatisfaction. See the previous Member Services section following para- graph for information on the expedited decision process. MembersNote: Blue Shield of California has established a procedure for our Members to request an expedited decision. A Mem- ber, a designated representativePhysician, or representative of a provider on behalf 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 the Member request. An ex- pedited decision may contact the MHSA by telephoneinvolve admissions, letter continued stay, or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted belowother healthcare services. If you would like additional infor- mation regarding the telephone in- quiry to the MHSAexpedited decision process, or if you believe your particular situation qualifies for an expedited decision, please contact Blue Shield of California’s Member Services Department does not resolve at the question or issue to number provided in the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf back of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance your Evidence of Coverage and Disclosure Form. Completed grievance forms must be mailed Note: If your Employer’s health plan is governed by the Em- ployee Retirement Income Security Act (“ERISA”), you may have the right to the MHSA at the address provided below. The Member may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 Blue Shield bring a civil action under Section 502(a) of California Mental Health Service AdministratorERISA if all required reviews of your claim have been com- pleted and your claim has not been approved.

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking Members’ griev- ances grievanc- es with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member may contact the Member Services Department by telephone, letter or online to request a review of an initial determination concerning a claim or service. Members may contact the Plan at the telephone number as noted on the last page of this booklet. If the telephone inquiry to Member Ser- vices does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Member’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting submit- ting a letter or a completed “Grievance Form”. The Member may request this form from Member Services. The completed form should be submitted to Member Services Appeals and Grievance, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000. The Member may also submit the grievance online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject sub- ject of the Member’s dissatisfaction. See the previous Member Mem- ber Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry inquiry to the MHSA’s Member Services Department does not resolve re- solve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting submit- ting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Grievance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member 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

Grievance Process. Blue Shield of California has established a grievance proce- dure procedure for receiving, resolving and tracking MembersSubscribers’ griev- ances grievances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Member, may contact the Member Services Department by telephone, letter or online to request a review of an initial determination concerning a claim or service. Members may contact the Plan at the telephone number as noted on the last page of this Evidence of Coverage booklet. If the telephone inquiry to Member Ser- vices Services does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Member’s behalf. The Member, a designated representative, or a provider on behalf of the Member Member, may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. .” The Member may request this form Form from Member Services. The completed form should be submitted to Member Services Services, Appeals and Grievance, X.X. Xxx 0000P.O. Box 5588, Xx Xxxxxx XxxxxEl Dorado Hills, XX 00000CA 95762-00000011. The Member may also submit the grievance online by visiting our web site at xxxx://xxx.xxxxxxxxxxxx.xxx. Blue Shield will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s dissatisfaction. See the previous Member Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf of the Member Member, may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing concerning a claim or service. Members may contact the MHSA at the telephone number as noted below. If the telephone in- quiry inquiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request a grievance at that time, which the Member Services Representative will initiate on the Mem- berMember’s behalf. The Member, a designated representative, or a provider on behalf of the Member Member, may also initiate a grievance by sub- mitting submitting a letter or a completed “Grievance Form”. .” The Member may request this form Form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Grievance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 0000‌ Blue Shield of California Mental Health Service AdministratorAdministrator P. O. Box 719002 The MHSA will acknowledge receipt of a grievance within 5 calendar days. Grievances are resolved within 30 days. The grievance system allows Members to file grievances for at least 180 days following any incident or action that is the subject of the Member’s dissatisfaction. See the previous Member Services section for information on the expedited decision process. For all Services‌

Grievance Process. Blue Shield of California has established a grievance proce- dure for receiving, resolving and tracking Members’ griev- ances with Blue Shield of California. Members, a designated representative, or a provider on behalf of the Member Member, may contact the Dental Member Services Department De- partment by telephone, letter letter, or online on-line to request a review of an initial determination concerning a claim or serviceService. Members Mem- bers may contact the Plan Dental Member Services Department at the telephone number as noted on the last page of this bookletbelow. If the telephone inquiry to the Dental Member Ser- vices Services Department does not resolve the question or issue to the Member’s 's satisfaction, the Member may request a grievance at that time, which the Member Dental Mem- ber Services Representative will initiate on the Member’s behalf's be- half. The Member, a designated representative, or a provider on behalf be- half of the Member Member, may also initiate a grievance by sub- mitting submit- ting a letter or a completed “"Grievance Form”". The Member may request this form Form from Member Services. The completed form should be submitted to the Dental Member Services Appeals and GrievanceDe- partment. If the Member wishes, X.X. Xxx 0000, Xx Xxxxxx Xxxxx, XX 00000-0000the 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 provided below. The Member may also submit the grievance online to the Dental Member Services De- partment on-line by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 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 5 calendar days. Grievances are resolved within 30 calendar days. The grievance system allows Members to file grievances for at least within 180 days following any incident or action that is the subject sub- ject of the Member’s enrollee's dissatisfaction. See the previous Member Services section for information on the expedited decision process. Members, a designated representative, or a provider on behalf The California Department of the Member may contact the MHSA by telephone, letter or online to request a review of an initial determination concern- ing a claim or service. Members may contact the MHSA at the telephone number as noted belowManaged Health Care is respon- sible for regulating health care service plans. If the telephone in- quiry to the MHSA’s Member Services Department does not resolve the question or issue to the Member’s satisfaction, the Member may request you have a grievance against your health plan, you should first telephone your health Plan at that time, which the Member Services Representative will initiate on the Mem- ber’s behalf. The Member, a designated representative, or a provider on behalf of the Member may also initiate a grievance by sub- mitting a letter or a completed “Grievance Form”. The Member may request this form from the MHSA’s Member Services Department. If the Member wishes, the MHSA’s Member Services staff will assist in completing the Griev- ance Form. Completed grievance forms must be mailed to the MHSA at the address provided below. The Member may also submit the grievance to the MHSA online by visiting xxxx://xxx.xxxxxxxxxxxx.xxx. 0-000-000-0000 and use your health Plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, 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 assistance. You may also be eligible for an independent medical review (IMR). If you are eligible for IMR, the IMR process will pro- vide an impartial review of medical decisions made by a health Plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are Experi- mental or Investigational in Nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (0-000-000-0000) and a TDD line (0-000-000-0000) for the hearing and speech impaired. The Department’s internet website (xxxx://xxx.xxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. In the event that Blue Shield should cancel or refuse to renew the enrollment for you or your Dependents and you feel that such action was due to reasons of California Mental health or utilization of Ben- efits, you or your Dependents may request a review by the De- partment of Managed Health Service AdministratorCare Director.