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EAP Services Agreement 6 If the complaint or grievance involves a delay, modification, or denial of service related to a clinically emergent or urgent situation, the review will be expedited and a response provided in writing to the Member within three (3) days from receipt of the complaint or grievance. There is no requirement that the Member participate in Plan’s grievance process before requesting a review by the California Department of Managed Care (“Department”) in any case determined by the Department to be a case involving an imminent and serious threat to the health of the patient, including but not limited to severe pain, the potential loss of life, limb, or major bodily function, or in any other case where the Department determines that an earlier review is warranted. The criteria for determining emergent situations are whether the Member is assessed to be at imminent risk to seriously harm himself or another person, or is so impaired in judgment as to destroy property or be unable to care for his own basic needs. The criteria for determining urgent situations are whether the Member is assessed to be significantly distressed, and is experiencing a reduced level of functioning due to more than a moderate impairment resulting in an inability to function in key family/work roles. A Member, or the agent acting on behalf of the Member, may also request voluntary mediation with Plan prior to exercising the right to submit a grievance to the Department. The use of mediation services will not preclude the Member’s right to submit a grievance to the Department upon completion of the mediation. In order to initiate mediation, the Member, or the agent acting on behalf of the Member, and Plan will voluntarily agree to mediation. Expenses for the mediation will be borne equally by the parties. The Department will have no administrative or enforcement responsibilities in connection with the voluntary mediation process. Mediations will take place in San Diego, California unless otherwise determined by the parties. Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been canceled or not renewed because of his health status or requirement for services may request review by the Department. The California Department of Managed Health Care is responsible for regulating health care service plans. If a member has a grievance against the health plan, the member should first telephone the health plan at (1-800-342-8111) and use the 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 the member. If a member needs help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by the health plan, or a grievance that has remained unresolved for more than 30 days, the member may call the department for assistance. The member may also be eligible for an Independent Medical Review (IMR). If the member is 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 proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. Plan’s grievance process and the department’s complaint review process are in addition to any other dispute resolution procedures that may be available to the member, and the member’s failure to use these processes does not preclude the member’s use of any other remedy provided by law. REV: 03-10-23 MI ATTY/AGR.2023.039/Aetna (EAP Services Agreement) (Page 7 of 42)