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Looking for an approved HICE document/template? They can be found in the Approved HICE Documents folder - click here for a list of available documents for each HICE team: APPROVED HICE DOCUMENTS.


Health Plan Specific Letter Templates

 Click to close category Health Plan Specific Letter Templates  
     Click to open category 01_Template Instructions
HICE posts whatever templates have been uploaded by participating health plans. Please contact the health plans directly for any templates not available on the HICE website. To receive broadcast messages when letter templates are added/updated by participating health plans, add the "Health Plan Specific Letter Template Notifications" Team to your HICE account (see Teams" page for instructions on how to do this or contact admin@iceforhealth.org if assistance is needed)
     Click to close category Click to Download All Documents in Subfolder Aetna
       File   Upload   Review
  Title     Size   Date   Date
  Aetna_UM_Comm_LAP_Option 2_CA State Taglines 0218 GT ID 2017 V 2.1   469 KB   2/21/2018   2/15/2021
  Aetna_UM_Comm_LAP_Option 2_Approval FI California_rev 021318   127 KB   2/21/2018   2/15/2021
  10-20 CA ONLY_AETNA_UM_MA_ME09_Notice of Medicare Non-Coverage   116 KB   10/27/2020   
  10-20 CA ONLY_AETNA_UM_MA_ME03_Medicare_14_day_ext_for_expedited   107 KB   10/27/2020   
  10-20 CA ONLY_AETNA_UM_MA_ME07 Medicare Approval Letter   105 KB   10/27/2020   
  10-20 CA ONLY_AETNA_UM_MA_ME12_Medicare expedited denial   95 KB   10/27/2020   
  10-20 CA ONLY_AETNA_UM_MA_ME04_Medicare_14_day_ext_for_standard   94 KB   10/27/2020   
  12-20_CA_ONLY_AETNA_UM_MA_DENC AETNA ME11_ (Spanish version)   93 KB   1/7/2021   
  12-20_CA_ONLY AETNA_UM_MA_ME09_Notice of Medicare Non Coverage_Spanish   89 KB   1/7/2021   
  Aetna_Claims_Commercial_HCR_Denial Ltr_12042018   76 KB   12/14/2018   2/8/2022
  Aetna_UM_Comm_LAP_Option 2_CA Comm Service Denial Notice (CSDN)_rev 052020   71 KB   6/23/2020   
  10-20 CA ONLY_AETNA_UM_MA_CMS_10003_NDMCP_ Notice of Denial of Med Cov_SPANISH_   67 KB   10/27/2020   
  10-20 CA ONLY_AETNA_UM_MA_CMS-10003_DMCP_Notice of Denial of Medical Coverage   64 KB   10/27/2020   
  CA ME17-Aetna_UM_MA_Enrollment Source ID 42-All Other Dismissal Reasons-2022_rev   64 KB   6/15/2022   
  CA ME17-Aetna_UM_MA_Enrollment Source ID 42-No Authority-2022_rev   63 KB   6/15/2022   
  Aetna_UM_Comm_LAP_Option 2_CA Only_Specialist_Termination_Commercial_Letter_0320   49 KB   4/2/2020   
  10-20 CA ONLY_AETNA_UM_MA_DND Y0001_3035_10918_NM_ENG CMS 10066   49 KB   10/27/2020   
  1020_CA ONLY_AETNA_UM_MA_Provider_Retraction_Medicare_Member_NR_0009_8530a   47 KB   10/27/2020   
  Aetna_UM_Comm_LAP_Option 2_CA Only_Provider_Retraction_Commercial_Letter_0320   42 KB   4/2/2020   
  10-20_CA_ONLY_AETNA_UM_MA_DENCenglishfinalword   41 KB   10/27/2020   
  1020_CA_ONLY_AETNA_UM_MA_PROVIDER No Longer In Network_Medicare_Member_NR_0009_10122   41 KB   10/27/2020   
  Aetna_UM_Comm_LAP_Option 2_CA State Taglines 0218   29 KB   2/21/2018   2/15/2021
  Aetna_UM_Comm_LAP_Option 2_CA Commercial Non-Discrimination Notice 0218   16 KB   2/21/2018   2/15/2021
     Click to open category Anthem Blue Cross
     Click to open category Blue Shield of California
     Click to open category Blue Shield of California Promise Health Plan
     Click to open category Brand New Day
     Click to open category Cigna
     Click to open category Health Net
Health Net Required Attachments - the Health Net Nondiscrimination Notice (NDN) and Multi Language Insert (MLI)/Taglines must be included in all Cal MediConnect (CMC) member letters. Use the Health Net Cal MediConnect English NDN and MLI for letters sent in English or one of the Translated Letters. In addition to the NDN and MLI, the Language Disclaimer & State Hearing Form must be attached to the HN_CMC_Medicaid_NOA_Deferral_LA_SD_County letter.
     Click to open category Humana
     Click to open category Inter Valley Health Plan
     Click to open category Sharp Health Plan
     Click to open category Wellcare Health Plan

HICE documents can be altered for use by organizations/other regions as needed; however, the HICE logo/any HICE references should be removed if the document is not being used in its original format. Documents available within the Library are intended to be used as printed documents. To the extent such documents are used digitally, it shall be the user's responsibility to ensure their use of the documents adheres to the accessibility standards applicable to their organization.


HICE is a voluntary 501(c)3 organization that includes participation by and advice from accrediting and regulatory agencies. The goal of HICE work products is to offer HICE participating organizations standardized tools and best practices toward optimizing efficiencies to implement health industry requirements. HICE heeds feedback from accrediting and regulatory agency partners regarding HICE work products; however, HICE does not obtain official regulatory approval for its work products. As such, HICE work products are not to be considered exempt from any approval process required by regulatory agencies.

   


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