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HomeMy WebLinkAboutMINUTES - 06211994 - 1.65 TO: BOARD OF SUPERVISORS Contra FROM: Joseph J. Tonda, Risk Manager i , 5 Costa DATE: June 21, 1994 n+ ��� County V SUBJECT: Vision Service Plan Contract Renewal SPECIFIC REOUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: AUTHORIZE THE COUNTY RISK MANAGER to approve and execute a contract renewal agreement with Vision Service Plan for the period of May 1, 1994 through April 30, 1995 for the purpose of providing video display terminal eye examinations to certain eligible employees. BACKGROUND: Through agreements with various bargaining units and certain court designated clerk classifications, it is necessary to renew the Vision Service Plan contract in order to continue providing uninterrupted video display eye examinations to certain eligible employees. FISCAL IMPACT: Program costs will be funded by participating County Departments and will depend upon eligible utilization of the program. JM:VSP CONTINUED ON ATTACHMENT; YES SIGNATURE: 4rn_q� Q RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF 04 RD OMMITT APPROVE OTHER SIGNATURE (S): ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVMORS 1 HEREBY CERTIFY THAT THIS IS A TRUE _Z'/UNANIMOUS(ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CC: CONTACT: Jean F. Soares - 6-1727 ATTESTED County Counsel PHIL TCHELOR,CLERK OF THE BOARD OF County Administrator 1 s.Off ice SUPERVISORS AND COUNTY ADMINISTRATOR Auditor—Controller Benefits Division Risk Management M382 (10/88) BY���v J0 ^� DEPUTY Contra Costa County Number Sbandar-d Yorm 1/87 . RENEWAL CONTRACT (Purchase of Services) Fund/Org # 1341 Account # 2310 / S36 1. Identification of Renewal Contract. DRAFT Other # YPSA17 Department: County Administrator - Risk Management Division Subject: VDT eye examinations 2. Parties. The County of Contra Costa, California (County) for its Department named above, and the following named Contractor mutually agree and promise as follows: Contractor: California Vision Service DBA Vision Service Plan Capacity: A California Non-Profit Corporation Taxpayer 1D# Address: 100 Howe Avenue Sacramento, CA 95825 3. Term. The effective date of this Renewal Contract is May 1. 1994 and it terminates April 30, 1995 unless sooner terminated as provided in the Prior Contract identified below. 4. Payment Limit. County's total payments to Contractor under this Renewal Contract shall not exceed $ 90,000 5. Prior Contract. By this Renewal Contract the parties agree to continue the Prior Contract hereby being renewed, the provisions of which are incorporated herein, subject to the provisions of Sections 3, 4 and 9 hereof. Prior Contract Number: , Term: May 1, 1993 - April 30, 1994 6. County's Obligations. County shall pay Contractor as described in the Payment Provisions of the Prior Contract. 7. Contractor's Obligations. Contractor shall provide those services and carry out that work described in the Service Plan of the Prior Contract. 8. General and Special Conditions. This Renewal Contract is subject to the General `Conditions and Special Conditions (if any) of the Prior Contract. 9. Additional Provisions. This Renewal Contract is subject to the Additional Provisions (if any) attached hereto, which are incorporated herein by reference, and which control over any conflicting provisions of the Prior Contract, or any amendments thereto. 10. Signatures. These signatures attest the parties' agreement hereto. COUNTY OF CONTRA COSTA, CALIFORNIA ATTEST: Phil Batchelor, Clerk of the Board BOARD OF SUPERVISORS of Supervisors and County Administrator By By ChairmanDesignee Deputy CONTRACTOR By By (Designate official business capacity A.) (Designate official business capacity B.) Note to Contractor: For corporations (profit or nonprofit) , the contract must be signed by two officers . Signature A .must be that of the president or vice-president and Signature B must be that of the secretary or assistant secretary (Civil Code §1190.1 and Corporations Code §313) . All signatures must be acknowledged as set forth on page two. APPROVALS/ACKNOWLEDGEMENT Number APPROVALS RECOMMENDED BY DEPARTMENT FORM APPROVED By By Designee APPROVED: COUNTY ADMINISTRATOR By Designee ACKNOWLEDGEMENT State of California ACKNOWLEDGEMENT (by Corporation, Partnership, or Individual) County of The person(s) signing above for Contractor, personally known to me in the individual or business capacity(ies) stated, or proved to me on the basis of satisfactory evidence to be the stated individual or the representatives) of the partnership or corporation named above in the capacity(ies) stated, personally appeared before me today and acknowledged that he/she/they exe- cuted it, and acknowledged to me that the partnership named above executed it or acknowledged to me that the corporation named above executed it pur- suant to its by-laws or a resolution of its board of directors. Dated: [Notarial Seal] Notary Public/Deputy County Clerk -2- contra costa county Standard Form 1/87 PAM-9W PROVISIONS (Fee Basis .Contracts) Number 1. Payment Amounts. Subject to the Payment Limit of this Contract and subject to the following Payment Provisions, County will pay Contractor the following fee as full compensation for all services, work, expenses or costs provided or incurred by Contractor: [Check one alternative only.] [ ] a. $ monthly, or [ ] b. $ per unit, as defined in the Service Plan, or [ ] c. $ after completion of all obligations and conditions herein. X d. See attached 2. Payment Demands. Contractor shall submit written demands. Said demands shall be made on County Demand Form D-15 and in the .manner and form prescribed by County. Contractor shall submit said demands for payment no later than 30 days from the end of the month in which the contract services upon which such demand is based were actually rendered. Upon approval of said payment demands by the head of the County Department for which this Contract is made, or his designee, County will make payments as specified in Paragraph 1. (Payment Amounts) above. 3. Right to Withhold. County has the right to withhold payment to the Contractor when, in the opinion of the County expressed in writing to the Contractor, (a) the Contractor's=performance, in whole or in part, either has not been carried out or_is insufficiently documented, (b) the Contractor has neglected, failed or refused to furnish information or to cooperate with any inspection, review or audit of its program, work or records, or (c) Contractor has failed to sufficiently itemize or document its demand(s) for payment. 4. Audit Exceptions. Contractor agrees to accept responsibility for receiving, reply- ing to, and/or complying with any audit exceptions by appropriate County, State or Federal audit agencies occurring as a result of its performance of this Contract. Contractor also agrees to pay to the County within 30 days of demand by County the full amount of the County's obligation, if'any, to the State and/or Federal government resulting from any audit exceptions, to the extent such are attributable to the Contractor's failure to perform properly any of its obligations under this Contract. Initials: Contractor ..County Dept . PAYMENT PROVISION 1.D. Within thirty (30) days of the termination of this contract,Vision Service Plan shall return $3,500 to County for the"Prefunding Amount"originally paid to Vision Service Plan and if such repayment is not timely received, County may reduce its future payments to Vision Service Plan by any portion of the $3,500 not repaid to County. Within fifteen(15)days after receiving a demand form,the County shall payto Vision Service Plan the amount of all Vision Service doctor's claims paid under this contract for the period covered by the demand, plus eighteen (18%) percent of such amount to compensate Vision Service Plan for its administration of the vision program provided hereby. Demands submitted by the first of each month will be paid by the County within fifteen (15)days of billing. Bills received after the first of the month will be paid by the fifteenth day of the following month. If the administrative fee is calculated upon the monthly claims total which is later corrected and reduced, Vision Service Plan shall within fifteen (15) days return to County any overpayment which exceeds eighteen (18%) percent of the corrected and reduced monthly claims total, or County may reduce its future payments to Vision Service Plan accordingly. Upon termination of this contract, county shall accept and pay demands for contract services provided during the term of this contract and not previously submitted for a period up to six (6) months from the date the contract terminates. JM:VSPPAY SERVICE PLAN Under this contract eligible employees must obtain a request for vision care form from the County Benefits Division and forward it when completed in a timely manner(within fourteen(14)days)to the Vision Service.Plan which will then provide the employee with an employee benefit form evidencing coverage for vision care under this plan which must be utilized within thirty(30)days. The employee will present the employee benefit form to the examining doctor for claims processing. A. Contractor agrees to: 1. Provide all benefit forms and personalized plan brochures to County for distribution to eligible employees. 2. Provide a panel of California licensed optometrists and ophthalmologists("doctors") to perform optometric examinations for eligible County employees. Such exams shall include eye refraction and testing for glaucoma and cataracts. The examination will analyze the employee's visual acuity with reference to the employee's use of a video display terminal. 3. Provide lenses and/or frames to eligible County employees for use during video display terminal operation, if deemed necessary after examination by the Vision Service Plan doctor. 1. Examination, Basic Single Vision Lenses (Regular of Pink Tint) Eligible. County employees are entitled to an eye examination under this program once every twelve(12)months. The Vision Service Pian doctor will prescribe proper lenses needed to use during the operation of a video display terminal. Eligible County employees are eligible for new lenses once every twelve (12) months for video display terminal use if replacement is determined to be necessary by the Vision Service Plan doctor. The maximum cost to the County, of a video display terminal eye examination,frames and lenses will be$150 per member, per year. The maximum benefit for frames, if necessary, is $10. A variety of frames will be available at a cost no greater than the maximum benefit amount. 2. Replacement Frames Eligible County employees may obtain new frames for video display terminal use once every twelve (12) months (up to a maximum benefit of$10) if the Vision Service Plan doctor determines that frame replacement is necessary. A variety of replacement frames will be available at a cost no greater than the maximum benefit amount. 4. Allow employees to obtain bifocal or trifocal lenses, if required, at the member's expense. 5. Allow employees to select other care, services or materials not covered by this plan as may be arranged between the member and their doctor at the member's expense such as frames costing more than the plan allowance. 6. Provide the County with a monthly billing and listing of all benefits paid to each eligible employee under this contract. 7. Maintain a control record of employee eligibility within the twelve(12)month benefit limitation. 8. Maintain and provide the County with all pertinent claims data on employee utilization, including responses to county generated questionnaires, upon request. 9. Maintain confidentiality of all patient information obtained pursuant to this contract. 10. Refuse to issue employee benefit forms if the request for vision care form is mailed more than fourteen(14)days after the date stamped on the employee's form by the County Benefits Division. Employee shall be given written notice of such refusal to issue an employee benefit form with a copy to the County Benefits Division - 651 Pine Street, 3rd Floor, Martinez, CA 94553. Notwithstanding the above, if an employee benefit form is not issued because of the employee's delay in forwarding the request to Vision Service Plan, an employee may obtain a new request for vision care form from the County Benefits Division and upon submitting the new request to Vision Service plan in a timely manner, an employee benefit form will be issued. 11. Limit the processing of claims under this contract to those eligible employees who obtain optometric exams under this program within thirty (30) days of the date appearing on the employee benefit form provided to that employee. Employee shall be given written notice of claim denials based upon delay in obtaining vision services with a copy to Contra Costa County Benefits Division at the address listed in paragraph(10) above. 12. Allow County to audit records of claims, denials and payments made under this contract on ten (10 working days notice to Vision Service Plan. County shall notify Vision Service Plan, in writing,of any overcharges discovered and Vision Service Plan shall return such overpayments to County within fifteen(15)days. 13. Provide coverage for services initiated but not yet completed to an eligible employee as of the termination date of this contract; such service shall be continued to completion, but in no event beyond thirty(30) days after the termination date of the contract. 14. Provide vision care services to those eligible County employees who are patients of former Vision Service Plan providers who leave the plan, either through the same provider,or,at the election of Vision Service Plan through another Vision Service Plan panel doctor. 15. Return to County the Prefunding Amount paid to Vision Service Plan, within thirty (30)days of termination of this contract. 16. Inform Vision Service Plan doctors that if an eligible employee wishes to select more expensive frames or lenses than that allowed under the program, the cost difference shall be by agreement between the eligible employee and the doctor. 17. Provide claims appeals procedures as specified in the exhibit A, attached hereto and incorporated herein. B. County agrees to: 1. Certify eligibility for all employees covered under the terms of this contract. 2. Provide video display terminal vision plan brochures and coverage information to all eligible County employees. 3. Cooperate with Vision Service Plan in disseminating to eligible County employees any materials as may be required. 4. Reimburse Vision Service Plan for its services as specified in the payment provisions. S. Assign an expiration date to each benefit request card. 6. Allow the inspection of County's group eligibility lists and payment records for the Vision Service Plan upon Vision Service Plan's request to confirm the number and eligibility of covered persons and accuracy of financial records. 7. Not engage in referring County eligible employees to any particular doctor,or doctors, whether or not a member of the Vision Service Plan panel. VGpGtttll. l,VI1L111UIVJ (Purchase of Services) 1. Compliance with Law. Contractor shall. be subject to and comply with all Federal, State and local laws and regulations applicable with respect to its perfor- mance under this Contract, including but not limited to, licensing, employment and purchasing practices; and wages, hours . and conditions of employment, including nondiscrimination. 2. Inspection. Contractor's.%performance, place of business and records per- taining to this Contract are subject to monitoring, inspection, review and audit by authorized representatives of the County, the State of California, and the United States Government. 3. Records. Contractor shall .keep and .make available for inspection and copying by authorized representatives of the County, the *State of California, and the United States Government, the Contractor's regular business records and such addi- tional records pertaining to this Contract as may be required by the County. a. Retention of Records. The Contractor shall retain all documents per- taining to this Contract for five years from the date of submission of Contractor's final payment demand 'or final Cost Report; for any further period .that As required by law; and until all Federal/State audits are complete and exceptions resolved for this contract's funding period. Upon request, Contractor shall, make these records avail- able to authorized representatives of the County, the State of California, and the United States Government. b. Access to Books and Records of Contractor, Subcontractor. Pursuant to Section 1861(v)(1) of the Social Security Act, and any regulations promulgated thereunder, Contractor shall, upon writtea request and until the expiration of four years of ter the furnishing of services pursuant to this Contract, make available to the Secretary of Health and Human Services or to the Comptroller General, or any of their duly authorized representatives, this Contract and books, documents, and records of Contractor that are.. necessary to certify the nature and extent of all costs and charges hereunder. Further, if Contractor carries out any of the duties .of this Contract through a subcontract with a value or cost of $10,000 or more over .a twelve-month period, such subcontract shall contain a clause to the effect that upon written request and until the expiration of -four years after the furnishing of. services pursuant to such -;.7- subcontract, _-subcontract, the subcontractor shall make available, to the County, to the Secretary or to the Comptroller General, or any of their duly authorized representatives, the subcontract and books, documents, and records of the subcontractor that are necessary to verify the nature and extent of all costs and charges thereunder. This special condition is in addition to any and all other terms regarding the main- tenance or retention of records under this Contract and is binding on the heirs, successors, assigns and representatives of Contractor. 4. Reporting Requirements. Pursuant to Government Code §7550, Contractor shall include in all documents or written reports completed and submitted to County in accordance with this Contract, a separate section listing the numbers and dollar amounts of all contracts and subcontracts relating to the preparation of each such document or written report. This section shall apply only if the payment limit under this Contract exceeds $5,000. -1- bL1YL ri1iL VVLYL LIIVLYJ (Purchase of Services) 5. Termination. a. Written Notice. This Contract may be -terminated by either party, at their sole discretion, upon thirty-day advance written notice thereof to the other, and may be cancelled immediately by written mutual consent. b�. Failure to Perform. The County, upon written notice.,to Contractor, may immediately terminate this Contract should the Contractor fail to perform properly any of its obligations hereunder. In the event of such termination, the County may proceed with the work in any reasonable manner it chooses. The cost to the County of completing Contractor's performance shall be deducted from any sum due the Contractor under this Contract, without prejudice to the County's rights otherwise to recover its damages. c. Cessation of Funding. Notwithstanding Paragraph 5.a. above, in the event that Federal, State, or other non-County .funding for this Contract ceases, this Contract is terminated without notice. . b. Entire Agreement. This Contract contains all the terms and conditions agreed upon by the parties. Except as expressly provided herein, no other understanding, oral or otherwise, regarding the subject matter of this Contract shall be deemed to exist or. to bind any of the parties hereto. 7. Further Specifications for Operating Procedures. Detailed specifications of operating procedures and budgets required by this Contract, including but not limited to, monitoring, evaluating, .auditing, billing,--or.-regulatory•changes;-may be•devel= oped and set forth, in a written Informal Agreement between the Contractor- and the County. Such Informal Agreements shall be designated as such and shall not be amendments to this Contract except to the extent that they further detail or clarify that Which is already required .hereunder. Such Informal Agreements may not enlarge in any manner. the scope of this. Contract, including any..sums of money to be paid the Contractor as provided herein. Informal Agreements may be approved and signed by the head of the County Department for which this Contract is made or his designee. 8. Modifications and Amendments. a. General- Amendments. This Contract may be modified or amended by a = _ written document executed by the Contractor and the Contra Costa County Board of Supervisors or, after Board approval, by its designee, subject to any required State or Federal approval. b. Administrative Amendments. Subject to the Payment Limit, the Payment Provisions and the Service Plan may be amended by a written administrative amendment executed by the Contractor and the County Administrator-.or his designee, subject to any required State of Federal approval, provided that such administrative amendments may not materially change the Payment Provisions or the Service Plan. 9. Disputes. Disagreements between the County and Contractor concerning the meaning, requirements, or performance of this Contract shall *be subject to final determination in writing by the bead of the County Department for which this Contract is made or his designee or in accordance with the applicable procedures (if any) required by the State or Federal Government. -2- GENERAL CONDITIONS (Purchase of Services) 10. Choice of Law and Personal Jurisdiction. a. This Contract is made in Contra Costa County and shall be governed and construed in accordance with the laws of the State of California. b. Any action relating to this Contract shall be instituted and prosecuted in the courts of Contra Costa County,. State of California, 11. Conformance with Federal and State Regulations and Laws. Should Federal or State regulations or laws touching upon the subject of this Contract be adopted or revised during the term hereof, this Contract shall be' deemed amended to assure conformance with such Federal or State requirements. 12. . No Waiver by County. Subject to Paragraph 9. (Disputes) of these General Conditions, inspections or approvals, or statements by any officer, agent or employee of the :County indicating the Contractor's performance or any part thereof complies with the requirements of this Contract, or acceptance of the whole or any part of said performance, or payments therefor, or any combination of these acts, shall not 'relieve the Contractor's obligation to fulfill this Contract as prescribed; nor shall the County be thereby estopped from bringing any action for damages or enforcement arising from any failure to comply with any of the terms and conditions of this Contract, 13. Subcontract and Assignment. This Contract binds the .heirs, successors, assigns and representatives of Contractor. The Contractor shall , not enter into subcontracts for Any woik contemplated under this Contract and 'shall not assign this Contract or monies due or to become due, without the. prior written consent of the County Administrator or his designee, subject to any required State or Federal approval. 14. Independent , Contractor Status. This Contract is by and between two independent contractors and is not intended to and shall not be construed to create the relationship between the parties of agent, servant, employee, partnership, joint venture or association. 15. Conflicts=of Interest= . Contractor, its officers, partners, associates, agents, and employees, shall not make, participate in making, -or in any way attempt to use the position afforded them by this Contract to influence any governmental decision in which he or she knows or has 'reason to know that he or she has a financial interest under California Government Code Sections 87100, - et seg., or otherwise. 16. Confidentiality. Contractor agrees to comply and to require its officers, partners, associates, agents and employees to comply with all applicable State or Federal statutes or regulations-respecting confidentiality, including but not limited to, the identity of persons served under this Contract, their records, or services provided them, and assures that: a. All applications and records concerning any individual made or kept by Contractor or any public officer or agency in connection with the administration of or relating to services provided under this Contract will be confidential, and will not be open to examination for any purpose not directly connected with the administration .of such service. -3- GENERAL CONDITIONS (Purchase of Services) b. No person will publish or disclose or permit or cause to be published or disclosed, any list of persons receiving services, except as may be required in the administration of such service. Contractor agrees to inform all employees, agents and partners of the above provisions, and that any person knowingly and intentionally disclosing such information other than as. authorized by law may be guilty of a misdemeanor. 17. Nondiscriminatory Services. Contractor agrees that all goods and services under this Contract shall be available to all qualified persons regardless of age, sex, race, religion, color, national origin, -)r ethnic background, or handicap, and that none shall be used, in whole or in part, for religious worship or instruction. 18. Indemnification. The Contractor shall defend, indemnify, save, and hold harmless the County and its officers and employees from any and all claims, costs and liability for any damages, sickness; death, or injury to person(s) or property, including without limitation all consequential damages, from any cause whatsoever arising directly or indirectly from or connected with the operations or services of the Contractor or its agents, servents, employees or subcontractors hereunder, save and except claims or litigation arising through the sole negligence or sole willful misconduct of the County or its officers or employees. Contractor will reimburse the County for any expenditures, including reasonable attorneys fees, the County may make by reason of the matters, that are the subject of this indemnification, and if requested by the County will defend any claims or litigation to which this indemnification provision applies at the sole cost and expense of the Contractor. 19. Insurance. During the entire term of this Contract and any extension or modification thereof, the Contractor shall keep in effect' insurance policies meeting the following insurance requirements unless otherwise expressed in the Special Conditions: a. Liability Insurance. The Contractor shall provide comprehensive liabi- lity insurance, including coverage for owned and non-owned automobiles, with a minimum combined single limit coverage of $500,000 for all damages, including consequential damages, due to bodily injury, sickness or disease, or death to- any person or damage to or destruction of property, including the loss of use thereof, arising from each occurrence. Such insurance shall be endorsed to include the County and its officers and employees as additional insureds as to all services performed by Contractor under this agreement. Said policies shall constitute primary insurance as _ - to the County,? the State and Federal Governments, and their officers, agents, and== - employees, so that other insurance policies held by them or their self-insurance program(s) shall not be required to contribute to any loss covered under the Contractor's insurance policy or policies. b. Workers' Compensation. The Contractor shall provide workers' compensation insurance coverage for its employees. c. Certificate of Insurance. The Contractor shall provide the County with (a) certificates) of insurance evidencing liability and worker's compensation insurance as required herein no later than the effective date of this Contract. If the Contractor ' should renew the insurance policy(ies) or acquire either a new insurance policy(ies) or amend the coverage afforded through an endorsement to the policy at any time during the term of this Contract, then Contractor shall provide (a) current certificate(s) of insurance. d. Additional Insurance Provisions. The insurance policies provided by the Contractor shall include a. provision for thirty (30) days written notice to County before cancellation or material change of the above specified coverage. -4- GENERAL CONDITIONS (Purchase of Services) 20. Notices. All notices provided for by this Contract shall be In writing and may be delivered by deposit in the United States mail, postage prepaid. Notices to the County shall be addressed to the -bead of the County Department for which this Contract is made. N6tices to the Contractor shall be addressed to the Contractor's address designated herein. The effective date of notice shall be the date of deposit in the mails or of other delivery, except that the effective date of notice to the County shall be the date of receipt by the head of the County Department for which this Contract is made. 21. 'Primacy of General Conditions. Except for Special Conditions which expressly supersede General Conditions, the Special Conditions (if any) and Service plan do not limit any term of the General Conditions. 227. Nonrenewal. Contractor understands and agrees that there Is no representation, Implication, or understanding that the services provided by Contractor under this Contract will be purchased by County under"a new contract following expiration or termination of this Contract, and waives all rights or claims to notice or hearing respecting any failure to continue purchase of all or any such services from Contractor. 23. Possessory Interest. If this Contract results in the Contractor having possession of, claim to or right to the possession of land or improvements, but does not vest ownership of the land or improvements in the same person, or if this Contract results in the placement of taxable improvements'o'n'taix exempt land.(Revenue & Taxation Code §107), such interest or improvements may represent a possessory interest subject to property tax, and Contractor may be subject to the payment of property taxes levied on such interest. Contractor agrees that this provision complies with the notice requirements of Revenue & Taxation Code §107.6, and waives all rights to further notice or%to damages under that or any comparable statute. 24. No Third-Party Beneficiaries. Notwithstanding mutual recognition that services under this Contract may provide some aid or assistance to members of the County's population, it is not the intention of either the County or Contractor that such individuals_ occupy the position of intended third-party beneficiaries of the obligations assumed by either party to this Contract. 25. Copyrights and Rights in Data. Contractor shall not publish or transfer any materials produced or resulting from activities supported by this agreement without the express written consent of the County Administrator. If any material is subject to copyright, the County reserves the right to copyright such and the Contractor agrees not to copyright such material. If the material is copyrighted, the County reserves a royalty-free, nonexclusive,- and irrevocable license to reproduce, publish, and use such materials, in whole or in part, and to authorize others to do so. -5- EXHIBIT A CLAIMS APPEAL PROCEDURES COMPLAINTS - BENEFIT ELIGIBILITY 1. If a claim for benefits is denied, Vision Service Plan will notify the claimant in writing of the specific reasons for the denial, including specific references to pertinent plan provisions. Vision Service Plan will also describe any additional materials or information necessary. 2. If the claimant, or the duly authorized representative, so requests within ninety(90)days of the date of receipt of written denial of the claim the plan administrator whose address is 100 Howe Avenue, Sacramento, CA 95825 will review the decision denying the claim. 3. The plan administrator will give the claimant a reasonable opportunity for a full and fair review of the decision denying the claim. The claimant will be given the opportunity to review pertinent documents, and to submit any statements, documents, or written arguments in support of this claim, and may, if so desired, appear personally at the Vision Service Plan office, 100 Howe Avenue, Sacramento, California 95825, to present the complaint to the Professional Relations Vice President. 4. If the claim is denied, the plan administrator will, within sixty (60) days after receipt of the request for review, advise the claimant in writing of the specific reasons for the decision, including specific references to the pertinent plan provisions on which a decision is based. COMPLAINTS - PROFESSIONAL SERVICES 1. The patients written complaint will be referred to the Vision Service Plan's Professional Relations Vice President for his action. 2. The complaint will be evaluated and, if deemed appropriate, the original examining doctor will be contacted. 3. If the complaint can be resolved within fifteen(15)days,the disposition of the complaint will be forwarded to the complainant. Otherwise,a notice of receipt of the complaint will be forwarded to the complainant advising the appropriate time for resolution. 4. Grievance procedures and complaint forms will be maintained in each Panel Doctor's office. 5. All complaints will be retained in the Professional Relations Department. IF GROUP OR COVERED PERSONS HAVE ANY QUESTIONS ABOUT BENEFITS OR PROFESSIONAL SERVICES RECEIVED, CONTACT VISION SERVICE PLAN, 100 HOWE AVENUE, SACRAMENTO, CALIFORNIA 95825, OR PHONE (916) 481-8720.