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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
Health Plan Specific Letter Templates
01_Template Instructions
Participating health plans that have confirmed the templates have been reviewed to determine regulatory compliance are able to use a self-service web-based tool to upload their health plan-specific templates to this site. Please contact the plans directly for any templates not available on the HICE website. To receive broadcast messages when letter templates are added/updated by participating 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).
Aetna
Anthem Blue Cross
		File	Upload	Review
	Title	Size	Date	Date
	01_Anthem_Blue_Cross_CA_UM_Medi-Cal_INSTRUCTIONS_FOR_USING_NOTICES_OF_ACTION_rev_02.2022	142 KB	2/16/2023
	01_DMHC IMR Website Link	15 KB	2/16/2023
	03_Anthem_Blue_Cross_UM_Medi-Cal_Your_Rights_Attachments	674 KB	2/16/2023
	04_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State_Fair_Hearing_Attachments	6626 KB	2/16/2023
	05_Anthem_Blue_Cross_UM_Medi-Cal_NOA_DENIAL_Templates	3803 KB	2/16/2023
	06_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Modify_Templates	6953 KB	2/16/2023
	07_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Carve-out_Templates	412 KB	2/16/2023
	08_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Spec_Term_Letter_Templates	3185 KB	2/16/2023
	09_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Delay_Templates	253 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_Carve_Out_Template_02.2012	43 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_Clinical_MLI_Insert_Standard_01.01.23	371 KB	2/16/2023
	Implementation Date for Notice/Description: 1/1/23
	Anthem_Blue_Cross_UM_Medicare_HMO_DENC_9.16	75 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice	37 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_HMO_Extension_Standard_Expedited_Review_Ltr_11.16.17	50 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_11.16.17	51 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_NOMNC_05.23.19	41 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_Notice_of_Reinstatement_of_Coverage_02.27.12	41 KB	2/16/2023
	Anthem_Blue_Cross_UM_Medicare_Specialist_Term_Template_For Delegate Use_10.2020	62 KB	2/16/2023
	Anthem_Blue_Cross_UM_Commercial_Authorization_Notification_rev_5.16.17	163 KB	2/16/2023
	Anthem_Blue_Cross_UM_Commercial_CA_Only_Delegate_Specialist_Term_10.2020	35 KB	2/16/2023
	Anthem_Blue_Cross_UM_Commercial_Pended_Notification_Template_rev_5.16.17	114 KB	2/16/2023
	Anthem_Blue_Cross_UM_Commerical_Carve_Out_Letter_Template_rev_5.16.17	164 KB	2/16/2023
	Anthem Blue Cross_UM_CA EAE_Int Cov Dec_TEMPLATES(1)	89536 KB	3/28/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem Blue Cross_UM_CA EAE_NDN_MLI_TEMPLATES(1)	10064 KB	3/28/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem Blue Cross_UM_CA EAE_Your Rights_Notices	8188 KB	4/7/2023
	Implementation Date for Notice/Description: 1/1/2023
	02_Anthem_Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_All_Languages_1	15790 KB	4/7/2023
	Anthem Blue Cross_UM_CA EAE_State Fair Hearing Attachments	412 KB	6/14/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem_Blue_Cross_CLAIMS_CA_EAE_State Fair Hearing Attachments	6617 KB	6/14/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem_Blue_Cross_CLAIMS_CA_EAE_Inter Cov Dec_TEMPLATES	91180 KB	6/14/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem_Blue_Cross_CLAIMS_CA_EAE_MLI_TEMPLATES	11108 KB	6/14/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem_Blue_Cross_CLAIMS_CA EAE_Your Rights_Notices	11241 KB	6/14/2023
	Implementation Date for Notice/Description: 1/1/2023
	Anthem_Blue_Cross_Claims_Medicare_CMS IDN_Notice of Denial of Payment_2023.03_ENGLISH_v2	43 KB	7/21/2023
	Anthem_Blue_Cross_Claims_Medicare_CMS IDN_Notice of Denial of Payment_2023.03_SPANISH_v2	43 KB	7/21/2023
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_CHINESE_v2	47 KB	7/21/2023
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_ENGLISH_v2	41 KB	7/21/2023
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_SPANISH_v2	39 KB	7/21/2023
	Anthem_Blue_Cross_UM_Commercial_Service_Denial_Notice_(CSDN)_rev_08.15.2023 (Clean)	121 KB	8/16/2023
	Implementation Date for Notice/Description: 8/16/2023
Cigna
Clever Care Health Plan
Health Net
Sharp 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.