• Grievance Procedure
• Organ and Tissue Donations
• Health and Human Resource Center, Inc. DBA Aetna Resources for Living Corporate Compliance/Anti-Fraud Helpline

NOTICE TO PLAN ENROLLEES

When Aetna acquired Horizon Health Employee Assistance Program, it then had two companies licensed to operate EAP plans in California, Aetna Health of California Inc. and Health and Human Resource Center, Inc. Beginning January 1, 2013, employers with Aetna Health of California EAP contracts will begin to transition to Health and Human Resource Center contracts.

Because the two EAP plans already use the same provider networks, this transition will not impact your access to EAP services. You will still access EAP through the same toll-free phone number that you have had in the past. There are no changes to benefits or services as a result of this change.

If you have any questions concerning this change, please contact Aetna at (800) 342-8111 or Health and Human Resource Center, Inc. DBA Aetna Resources for Living at (800) 342-8111. Language assistance services are available to you through the Employee Assistance Program, at no charge.

Annual Enrollee Notification Regarding Grievances

Health and Human Resource Center, Inc. DBA Aetna Resources for Living is committed to ensuring high quality care and customer service. Should you at any time have any concerns, complaints or grievances related to Health and Human Resource Center, Inc. DBA Aetna Resources for Living, please inform the Director, Quality Improvement, in writing or by telephone at:

Health and Human Resource Center, Inc. DBA Aetna Resources for Living
Attn: Director, Quality Improvement
10260 Meanley Drive
San Diego, CA 92131
Voice: (800) 342-8111
Fax: (800) 293-1967

Upon receipt of a complaint or grievance the Director, Quality Improvement, researches and investigates the matter in question and works quickly to correct or resolve the problem. Health and Human Resource Center, Inc. DBA Aetna Resources for Living is committed to resolving all concerns or grievances within 30 days. Should you feel that the situation is especially urgent, you may simply ask for an expedited grievance review and the matter will be resolved within 3 days.

All policies related to the Health and Human Resource Center, Inc. DBA Aetna Resources for Living EAP/HHRC Grievance and Expedited Grievance processes are available to enrollees upon request.

California Residents:

COMPLAINT AND GRIEVANCE PROCEDURE

A grievance is a written or oral expression of dissatisfaction regarding Health and Human Resource Center, Inc. DBA Aetna Resources for Living and/or an EAP Provider, including qualify of care concerns, and includes a complaint, dispute, request for reconsideration or appeal made by a Member or the Member’s representative. A complaint is the same as a grievance. There is no discrimination by the plan against a Member for filing a grievance. Members are entitled to present complaints and grievances. Health and Human Resource Center, Inc. DBA Aetna Resources for Living is obliged to seek to resolve such complaints and grievances in a timely fashion. Members may file a grievance up to 365 calendar days following an incident or action that is the subject of the enrollee’s dissatisfaction. Health and Human Resource Center, Inc. DBA Aetna Resources for Living has established a procedure for processing and resolving Member complaints and grievances. Should a Member desire to register a complaint or grievance with Health and Human Resource Center, Inc. DBA Aetna Resources for Living concerning Benefits, he/she can either call Health and Human Resource Center, Inc. DBA Aetna Resources for Living at the toll-free telephone number 1-800-342-8111 to report the complaint or grievance, or to request a copy of the Health and Human Resource Center, Inc. DBA Aetna Resources for Living Complaint Form, or write directly to Health and Human Resource Center, Inc. DBA Aetna Resources for Living at 10260 Meanley Drive, San Diego, CA 92131. The telephone call or letter should be addressed to the Director, Clinical Quality Improvement. Health and Human Resource Center, Inc. DBA Aetna Resources for Living will acknowledge each complaint and grievance within five (5) days of receipt. The Director, Clinical Quality Improvement will receive and investigate all Member complaints and grievances. The Director, Clinical Quality Improvement will respond to the Member stating the disposition and the rationale within thirty (30) days of receipt of the grievance. If the grievance is not resolved to the Member’s satisfaction, a second level of review may be requested within ten (10) days of notification of such disposition. Any such request will be reviewed by the Medical Director and responded to within seventy-two (72) hours of receipt. 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 Health and Human Resource Center, Inc. DBA Aetna Resources for Living’ 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 that an earlier review is warranted. 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 Health and Human Resource Center, Inc. DBA Aetna Resources for Living 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 upon completion of the mediation. In order to initiate mediation, the Member, or the agent acting on behalf of the Member, and Health and Human Resource Center, Inc. DBA Aetna Resources for Living 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.

REVIEW BY THE DEPARTMENT OF MANAGED HEALTH CARE

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. The Department has a toll-free telephone number (1-888-HMO-2219) to receive complaints regarding health plans. The hearing and speech impaired may use the California Relay Service’s toll-free telephone number (1-877-688-9891) (TDD) to contact the Department. The Department’s Internet website (http://www.hmohelp.ca.gov ) has complaint forms, IMR application forms and instructions online. If you have a grievance against your health plan, you should first telephone your plan at 1-800-342-8111 and use the plan’s grievance process before contacting the department. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your plan within 30 days, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of the medical decisions made by your 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 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 you, and your failure to use these processes does not preclude your use of any other remedy provided by law.

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Organ and Tissue Donations

Donating organ and tissue provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives. Currently, the need for organ transplants far exceeds availability. If you are interested in organ donation, please speak with your physician. Organ donation begins at the hospital when a patient is pronounced brain dead and identified as a potential organ donor. An organ procurement organization will become involved to coordinate the activities.

Consider Becoming an Organ or Tissue Donor

With a simple decision you can become an organ or tissue donor and perhaps help one or more of the estimated 60,000 Americans waiting each year for an organ or tissue transplant. Your donation could save a life.

Health and Human Resource Center, Inc. DBA Aetna Resources for Living encourages those of you who can donate (there are some restrictions for some donations) to sign a donor card and keep it with your driver's license. Discuss your choice with your family so they are prepared in advance. They will have to consent to your organ donation even if you have signed a donor card. Family members can contest your decision, preventing your donation, so be clear with them about your wishes.

For answers to your questions about organ donation, please call the regional organ procurement agency in the city nearest you. The phone numbers are listed below:

Los Angeles: (213) 413-6219
Orange County: (714) 480-1040
Riverside: (909) 774-0920
Sacramento/Santa Rosa: (916) 567-1600
San Diego: (619) 521-1983
Northern California, including San Franciso: (888) 570-9400

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Health and Human Resource Center, Inc. DBA Aetna Resources for Living Corporate Compliance/Anti-Fraud Helpline

A Corporate Compliance Helpline has been established to provide employees, providers and clients with a venue to raise issues and concerns regarding fraud, waste and/or abuse. Health and Human Resource Center, Inc. DBA Aetna Resources for Living has established this Helpline, to ensure that employees, providers and clients can report possible wrongdoings or unethical conduct occurring within or to Health and Human Resource Center, Inc. DBA Aetna Resources for Living without fear of retaliation. The Helpline is available seven days a week, twenty-four hours a day excluding designated holidays. Helpline calls are handled by the Compliance Officer to ensure confidentiality. Calls will not be recorded or traced and the caller will not be required to furnish his or her name. Calls will be investigated and the Corporate Compliance Officer will ensure follow-up actions are taken. Retaliation against employees, providers and clients for calling the Helpline is strictly prohibited.

Remember, every call will be treated confidentially and callers may remain anonymous.

Helpline: (800) 342-8111
Contact: Director, Quality Improvement

CRITICAL COMPLIANCE INFORMATION

To provide employees, providers and clients with every avenue possible to raise their concerns and report possible wrongdoing, Health and Human Resource Center, Inc. DBA Aetna Resources for Living has established an ANONYMOUS Corporate Compliance/Anti-Fraud Helpline.

If you are concerned about an ethical or legal compliance issue at Health and Human Resource Center, Inc. DBA Aetna Resources for Living, please report it immediately by using one or more of the following options:

1. Speak with your Supervisor, Manager or Director

2. Consult with the Corporate Compliance Officer

3. Report anonymously by calling Health and Human Resource Center, Inc. DBA Aetna Resources for Living Compliance/Anti-Fraud Helpline (1-800-342-8111)

1-800-342-8111

Health and Human Resource Center, Inc. DBA Aetna Resources for Living CORPORATE COMPLIANCE/ANTI-FRAUD HELPLINE ALWAYS WORKING FOR YOU!!