AMERICAN SPECIALTY HEALTH PLANS GROUP SUBSCRIBER AGMT 1998

.. ~ , 7.01.01 ASHP Grievance Procedure. The following procedure will be followed in handling Member complaints not related to quality of care: a. The Member complaint is received either by telephone or in writing through the Member Services Department. If the complaint is by telephone and the person taking the call is unable to resolve the problem to the satisfaction of the Member, the Member will be asked to submit a written complaint. The Member Services Department representative will assist the member in filing a written complaint if the Member so requests. b. All complaints are directed to the Member Services Manager. The Member Services Manager will conduct an initial review within three (3) business days and will refer all complaints that do not involve a quality of care issue to the Member Services Department for review pursuant to the Grievance Procedures. Quality of care complaints are handled pursuant to the Quality Assurance Program described in Section 7.01.02 below. c. After receipt of the complaint, the Member Services Department shall conduct a review in coordination with an ASHP Reviewing Chiropractor, and if appropriate consult with at least three other Participating Chiropractors who are member of ASHP's Quality Assurance Committee. d. The Reviewing Chiropractor and the Participating Chiropractors shall each submit their written evaluations to ASHP's Chiropractic Director. The Chiropractic Director, in coordination with the Member Services Manager, shall make an initial determination on the matter. e. ASHP shall send a written initial determination to the Member within thirty (30) days of the receipt of a complaint. f. If the Member is dissatisfied with the initial determination, the Member may request another review by ASHP's Chiropractic Director by submitting a written request within fifteen (15) days from the receipt of the initial determination. The Member may submit to ASHP any additional information which Member believes would assist ASHP in making a redetermination. The Chiropractic Director shall review the Member's complaint and may consult with any Participating Chiropractor regarding Member's complaint. The Chiropractic Director shall provide a written determination to Member within fifteen (15) days from the date of receipt for redetermination. . g. If the complaint is not resolved to the Member's satisfaction by ASHP's Chiropractic Director, the Member may request a redetermination in writing within thirty (30) days by ASHP's President. ASHP's President may consult with any Participating Chiropractor who is a member of ASHP's Quality Assurance Committee. If ASHP's President agrees with the decision made by the Chiropractic Director, the Member's complaint shall be reviewed by ASHP's Board of Directors. A redetermination shall be rendered by the Board of Directors and sent to the Member within thirty (30) days of the request for the redetermination. h. After the decision by ASHP's Board of Directors, the Member may submit or request ASHP to submit the complaint to binding arbitration before the American Arbitration Association. Upon submission of a dispute to the American Arbitration Association, Member and ASHP agree to be bound by the rules of procedure and decision of the American Arbitration Association. The findings and the award of the arbitrator shall be governed by applicable state and federal statutory and. case law. The parties agree that the arbitrator shall issue a written decision shall be binding and may be enforced in any court having any jurisdiction thereof. If a request for arbitration is not submitted within 60 days, the decision of the ASHP's Board of Directors shall be final and binding.