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<br />o Second step - Internal Review
<br />
<br />If you do not agree with OHS' determination made on a first step
<br />appeal, you may request in writing that your case be reconsidered.
<br />
<br />o Third Step - Internal Grievance Committee Hearing
<br />
<br />The final internal level of appeal available to you for resolution
<br />of a grievance is a hearing by OHS' Grievance Committee. Although
<br />the make-up of the Committee is subject to change at OHS'
<br />discretion, it is currently comprised of three administrative
<br />personnel of OHS. Hearings are usually scheduled within 30 days of
<br />written request. OHS will assist you in scheduling the hearing.
<br />This step is only available for disputes where the amount in
<br />controversy equals or exceeds $1,000. Disputes under this amount
<br />may only be finally decided by arbitration as set forth below.
<br />
<br />Members are allowed to appear with, and have information offered by
<br />third parties, including attorneys, but not insurance brokers or
<br />persons having a conflict of interest with OHS. However, unless
<br />incapacitated or a minor, the affected Member must appear in person
<br />and be principally responsible for the presentation of their
<br />grievance and for direct response to questions by the Committee.
<br />The hearing is conducted as an informal administrative hearing --
<br />formal rules of evidence and discovery which are common to legal
<br />hearings do not apply. In some cases, OHS may require the hearing
<br />to be conducted by telephonic conference.
<br />
<br />written requests for a hearing must be made directly by the affected
<br />Member (unless the Member is incapacitated or is a minor). Written
<br />requests by the treating physician or other Participating Provider
<br />will not be considered unless signed also by the Member. The
<br />written request should include all information that the Member
<br />wishes OHS and the Committee to consider. Information submitted
<br />after the hearing will not be considered in the review process. The
<br />written request must also contain an itemized statement as to the
<br />amount of money in dispute. If the Member does not attend the
<br />scheduled hearing, the Committee will decide the question on the
<br />basis of the information presented at that time. Requests for
<br />rescheduling of a scheduled hearing date will ordinarily only be
<br />considered if made at least ten days prior to the scheduled hearing
<br />date.
<br />
<br />o Final Step - Neutral, Binding Arbitration
<br />
<br />If the Member does not agree with OHS' final determination, the
<br />Member may, within 30 days of OHS' notice of its final
<br />determination, file a petition for neutral, binding arbitration in
<br />accordance with the California Arbitration Act (California Code of
<br />
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