Common use of Member Appeals and Grievances Clause in Contracts

Member Appeals and Grievances. PacifiCare shall be responsible for resolving Member claims for benefits under the Managed Care Plans and all other claims against PacifiCare. PacifiCare shall resolve such claims utilizing the Member Appeals and Grievance Procedures set forth in the Subscriber Agreement and the Provider Manual. Medical Group shall assist PacifiCare in the handling of Member complaints, grievances and appeals, consistent with the Member Appeals and Grievance Procedures. In the event an oral or written complaint, grievance or appeal is presented to Medical Group or any of its Participating Providers relating to benefits or coverage under a Managed Care Plan, Medical Group or its Participating Providers will immediately refer Members to contact PacifiCare or deliver any written complaint, grievance or appeal to PacifiCare for handling pursuant to the Member Appeals and Grievance Procedures. Medical Group and its Participating Providers shall comply with all final determinations made by PacifiCare through the Member Appeals and Grievance Procedures. Member claims against Medical Group or its Participating Providers, other than claims for benefits under the Managed Care Plans, are not subject to the Member Appeals and Grievance Procedures and are not governed by this Agreement.