Provider Grievance Policy …

                           Provider Grievance Policy
                      The Premier Provider Network, Inc. (PPNI)
                           11111 Richmond Ave., Suite 243
                               Houston, Texas 77082

                                       Introduction

PPNI encourages its providers to resolve any complaints or grievances through the
procedures outlined in this Grievance Policy. Grievances may be filed, and grievance
forms can be obtained, by mail, fax, telephone, or online as outlined below. If filing by
mail or fax, please use the Grievance Form enclosed in your provider packet or print the
form posted on the web.

If by mail, to PPNI, Attention: Sam Hamadeh, Director of Quality Assurance ­
Grievances, 11111 Richmond Avenue, Ste. 243, Houston, Texas 77082.

If by fax, submit the completed form to (713) 414-4953

If by telephone, call (866) 776-4872

If via the Internet, complaints can be emailed to: compliance@familycarecard.com or
the Grievance Form can be also be completed and submitted online                           at
www.ppnusa.com.


PPNI's Grievance Policy addresses the linguistic and cultural needs of its provider
population, as well as the needs of providers with disabilities. The system ensures all
providers have access to and can fully participate in the grievance system by providing
assistance for those with limited English proficiency, or with a visual or other
communicative impairment. Such assistance shall include, but is not limited to,
translations of grievance procedures, forms, and plan responses to grievances, as well
as access to interpreters, telephone relay systems, and other devices that aid disabled
individuals to communicate. Providers may file a grievance under this Grievance Policy
for up to one hundred and eighty (180) calendar days following any incident or action
which gives rise to the Provider's dissatisfaction.

PPNI is responsible for and will resolve service-related problems, including availability
and accessibility of providers, pricing or billing disputes, the sales process, and other
service-related problems. PPNI is not responsible for resolving quality of care-related
issues or providing medically necessary healthcare coverage to providers. PPNI will
assist providers in identifying and contacting the appropriate state professional licensing
agency to report quality of care­related problems (e.g. the Medical Board, Dental Board,
Department of Health Services, etc.) PPNI investigates all grievances and will take all
necessary steps to resolve any and all grievances including refunding provider fees as
appropriate. Our provider materials describe our complaint resolution procedure and
timeframes for handling all complaints or grievances.




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                                Documentation

1. PPNI will maintain a written record of each grievance submitted under this
   Grievance Policy. The written record shall include: the date the grievance was
   received; the name of the PPNI representative that processed the grievance; a
   summary or other documents explaining the nature of the grievance, how the
   grievance was handled, and a summary of the resolution.
2. PPNI will retain copies of grievances, responses, and resolutions for five years.
   When applicable the records shall contain all documents, evidence and other
   relevant information upon which PPNI relied in reaching its decision.
3. Grievance forms shall be available as outlined above. Additionally, PPNI will
   have the Grievance Policy and Grievance Forms posted on its websites and
   included in the Provider packets and provider packets, so that providers will have
   access to these forms in their initial packet as well as at each contracting
   provider's office or facility.
4. Grievances filed under this Grievance Policy shall not affect the provider's status
   in any way. PPNI will enforce a strict no-tolerance policy against discrimination
   based upon the filing of a grievance under this Grievance Policy.
5. Providers may file a grievance under this Grievance Policy for up to one hundred
   and eighty (180) calendar days following any incident or action which gives rise
   to the provider's dissatisfaction.

                           Response and Resolution

1. Grievances received under this Grievance Policy shall be acknowledged by an
   oral and/or written response. The response will advise the provider that their
   grievance has been received, the date of receipt, and provide the names of
   PPNI's department and representative, and telephone number and address of
   the PPNI representative who may be contacted about the grievance. All
   grievances will be resolved within thirty (30) calendar days from submission and
   will be reviewed from time to time by PPNI's officers and governing body to
   identify patterns regarding grievances as presented by the applicable
   management and supervisory staff.         A clear and concise response with the
   results of the investigation to the Provider will be provided within thirty (30)
   calendar days in writing.
2. Notwithstanding section one (1) above, grievances received by telephone that
   are resolved by the close of the next business day, will not be answered by
   written acknowledgment and response unless otherwise required by law. PPNI
   shall maintain a log of all grievances that do not require a written
   acknowledgement containing the date of the call, the name of the complainant,
   Provider identification number, nature of the grievance, nature of resolution, and
   the PPNI representative's name who took the call and resolved the grievance.
   PPNI shall periodically review the information contained in this log.
3. Grievance reports will be shared quarterly with the appropriate management and
   supervisory staff responsible for the Grievance to ensure Provider concerns are
   addressed.




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                      Grievance Tracking and Reporting

1. PPNI, through its responsible representatives, shall monitor the number of
   grievances received and resolved; whether the grievance was resolved in favor
   of the Provider or PPNI; and the number of grievances pending over thirty (30)
   calendar days. PPNI will distinguish complaints by whether a Provider grievance
   is pending at: (1) PPNI's internal grievance system; (2) the applicable State
   Regulatory Authority complaint process; (3) the applicable State Regulatory
   Authority Independent Medical Review system; (4) an action filed or before a
   trial or appellate court; or (5) other dispute resolution process.
2. PPNI will track the total number of grievances received, pending and resolved in
   favor of the Provider at all levels of grievance review and to describe the issue or
   issues raised in grievances as (1) coverage disputes, (2) complaints about
   access to care (including complaints about the waiting time for appointments),
   and (3) complaints about the quality of service, and (4) other issues.
3. PPNI is not responsible for resolving quality of care-related issues or providing
   medically necessary healthcare coverage to providers. PPNI will assist providers
   in identifying and contacting the appropriate state professional licensing agency
   to report quality of care­related problems (e.g. the Medical Board, Dental Board,
   Department of Health Services, etc.)
4. PPNI marketers must submit all grievances to PPNI within three (3) business
   days. All such grievances shall be handled in accordance with this policy.

                           Submission of Reports

1. If applicable, a report shall be submitted to the appropriate State Regulatory
   Authority describing grievances that were or are pending and unresolved for
   thirty (30) days or more. The report shall also contain the number of grievances
   referred to external review processes, such as the applicable State Regulatory
   Authority's complaint or Independent Medical Review system, or other external
   dispute resolution systems, known to PPNI.
2. The report filed by PPNI shall include:
                 (a) PPNI's name, period report covers, and date of the report;
                 (b) The total number of grievances filed by Providers that were or
                     are pending and unresolved for more than thirty (30) calendar
                     days at any time during the reporting period;
                 (c) A brief explanation of why the grievance was not resolved in
                     thirty (30) days, and indicate whether the grievance was or is
                     pending at: (1) PPNI's internal grievance system; (2) the
                     applicable State Regulatory Authority's consumer complaint
                     process; (3) the State Regulatory Authority's Independent
                     Medical Review system; (4) court; or (5) other dispute resolution
                     processes;
                 (d) The nature of the unresolved grievances listed as either (1)
                     coverage disputes;      (2) complaints about access to care
                     (including complaints about the waiting time for appointments);
                     (3) complaints about the quality of service; and (4) other issues.
                     All issues reasonably described in the grievance shall be
                     separately categorized.



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                    (e) The report shall not contain personal or confidential information
                        with respect to any Provider/Provider.
                    (f) The report shall contain the necessary information as prescribed
                        by the applicable State Regulating Authority.

   3. Prior to submitting the report to the applicable State Regulatory Authority, the
      Report shall be verified by an officer authorized to act on behalf of PPNI.
   4. PPNI's grievance reports shall be filed as prescribed by the applicable State
      Regulatory Authority.

                           State Specific Regulations
California

As a part of its Grievance Policy, PPNI will send an Annual Notice of Grievance
Procedures to its providers informing them of the California Department of Managed
Health Care's ("Department") review process, the Department's toll-free number and
website, as well as PPNI's Grievance Policy.

Grievances received under this Grievance Policy shall be acknowledged by written
response within five (5) calendar days.

                  Quarterly Reports Submitted to the Department

A quarterly report shall be submitted to the Department describing grievances that were
or are pending and unresolved for 30 days or more. The report shall be prepared for the
quarters ending March 31st, June 30th, September 30th and December 31st of each
calendar year. The report shall also contain the number of grievances referred to
external review processes, such as the Department's complaint or Independent Medical
Review system, or other external dispute resolution systems, known to PPNI as of the
last day of each quarter.

The quarterly report filed by PPNI shall include:
          (A)      PPNI's name, quarter and date of the report;
          (B)      The total number of grievances filed by Providers that were or are
                   pending and unresolved for more than 30 calendar days at any time
                   during the quarter;
          (C)      A brief explanation of why the grievance was not resolved in 30 days,
                   and indicate whether the grievance was or is pending at: (1) PPNI's
                   internal grievance system; (2) the Department's consumer complaint
                   process; (3) the Department's Independent Medical Review system;
                   (4) court; or (5) other dispute resolution processes;
          (D)      The nature of the unresolved grievances listed as either (1) coverage
                   disputes; (2) complaints about access to care (including complaints
                   about the waiting time for appointments); (3) complaints about the
                   quality of service; and (4) other issues. All issues reasonably
                   described in the grievance shall be separately categorized.
          (E)      The quarterly report shall not contain personal or confidential
                   information with respect to any Provider.




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   Prior to submitting the quarterly report to the Department the Report shall be verified
   by an officer authorized to act on behalf of PPNI. The report shall be submitted in
   writing or through electronic filing to the Department's Sacramento Office to the
   attention of the Filing Clerk no later than 30 days after each quarter. The quarterly
   report shall not be filed as an amendment to PPNI's application.

   PPNI's grievance reports shall be filed quarterly with the Department in the form
   specified by California law.




             Provider's Right to Submit Grievance Directly to the Department

   Notwithstanding the Grievance Policy above, after completion of the grievance
   processes described above or participation in those processes for thirty (30) days,
   PPNI Providers have the right to submit grievances directly to the Department by
   calling 1-888-466-2219 or TDD line 1-877-688-9891 for the hearing and speech
   impaired, or by visiting http://www.hmohelp.ca.gov PPNI providers must complete or
   participate in PPNI's grievance process for at least thirty (30) days before they may
   submit their grievance to the Department of Managed Health Care for review.
   However, 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, a
   subscriber or Provider shall not be required to complete the grievance process or to
   participate in the process for at least thirty (30) days before submitting a grievance to
   the Department for review.

   Upon notification from the Department that a Consumer has filed a grievance, PPNI
   will provide the following documents to the Department within five (5) calendar days:

        a)     A written response to the issues raised by the grievance.
        b)     If the grievance was first filed with PPNI, a copy of PPNI's original
               response sent to the Provider regarding the grievance.
        c)     A complete and legible copy of all factual records related to the
               grievance.
        d)     All other information used by PPNI or relevant to the resolution of the
               Grievance.
        e)     Any other information deemed necessary and appropriate by Family
               Care's management for the resolution of the grievance.


Texas

All grievances/complaints shall be acknowledged by written response within five (5)
calendar days.




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