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"complaints" are not distinguished) . How to file a grievance If after discussion with OHS a Member is dissatisfied with the result of OHS' initial determination regarding a claim, request for Prior Authorization of coverage or problem of any other nature related to this plan, the Member may appeal in writing to OHS within 30 calendar days of the date of OHS' notice of its determination. Any further appeal of OHS' response to a first or second step appeal must also be in writing and submitted to OHS within 30 calendar days of the date of OHS' notice of its determination as to the prior step. If the Member is still dissatisfied with OHS' determination, and the Member wishes to further appeal, a petition for arbitration must be filed with the arbitrator (as described below) within 30 calendar days of the date of OHS' notice of its final determination. APPEALS RECEIVED MORE THAN 30 CALENDAR DAYS AFTER THE DATE OF ANY OHS DETERMINATION WILL NOT BE CONSIDERED AND NO FURTHER INTERNAL OR EXTERNAL RESOLUTION IS AVAILABLE. Members are encouraged to call OHS at (800)227-1060 to discuss the grievance but all appeals must be made in writing and mailed to OHS at 125 East Sir Francis Drake Boulevard, suite 300, Larkspur, California, 94939-1860, Attention: Director of Quality Management. If you require assistance, OHS will assist you in writing the complaint. written appeals must be made and signed by the affected Member (unless incapacitated or a minor) and include any additional information that the Member wishes OHS to consider and an itemized statement as to the amount in dispute. OHS will respond with its determination within 30 calendar days following its receipt of an appeal, unless the Member is notified that additional time is required. Details of procedures for grievance resolution o First step - Internal Review Problems with eligibility, commencement of coverage, re-enrollment, access to providers, delivery of care, cost of care, Medical/Psychological Necessity, Covered Services or any other matter should be directed in writing by the Member to OHS. In the case of a grievance concerning a Participating provider, OHS will, upon receipt of a written grievance, conduct an investigation of the matter and implement appropriate disciplinary or corrective action if it determines that action is necessary. However, the findings of, and any actions resulting from, such peer review will not be disclosed to the grievant as they are privileged and protected from disclosure under law. No further steps of internal appeal are available for provider related grievances. - 12 - ,-""_..,,, "" "",""-,""",.',.-.""'--