Health Industry Collaboration Effort

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Looking for a final HICE document/template? They can be found in the Final HICE Documents folder - click here for a list of available documents for each HICE team: FINAL 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
	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_HMO_Extension_Standard_Expedited_Review_Ltr_11.16.17	50 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_Commercial_Service_Denial_Notice_(CSDN)_rev_08.15.2023 (Clean)	121 KB	8/16/2023
	Implementation Date for Notice/Description: 8/16/2023
	02A_Anthem Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_Standard Print	14132 KB	2/21/2024
	Implementation Date for Notice/Description: 3/21/2024
	02B_Anthem Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_Large Print	11700 KB	2/23/2024
	05B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_DENIAL_Templates_Large Print	1808 KB	4/24/2024
	Implementation Date for Notice/Description: 5/24/2024
	06B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Modify_Templates_Large Print	1743 KB	4/24/2024
	Implementation Date for Notice/Description: 5/24/2024
	09B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Delay_Templates_Large Print	1779 KB	4/25/2024
	Implementation Date for Notice/Description: 5/24/2024
	07B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Carve-Out_Templates_Large Print	1749 KB	4/25/2024
	Implementation Date for Notice/Description: 5/24/2024
	04A_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State Fair Hearing_Standard Print	3969 KB	6/5/2024
	Implementation Date for Notice/Description: 1/31/2024
	04B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State Fair Hearing_Large Print	9183 KB	6/5/2024
	Implementation Date for Notice/Description: 01/31/2024
	10_Anthem Blue Cross_UM_Medi-Cal_CoC_Acknowledgment_Letter_Templates	346 KB	11/20/2024
	Implementation Date for Notice/Description: 10/11/2024
	11_Anthem Blue Cross_UM_Medi-Cal_CoC_Approval_Letter_Templates	450 KB	11/20/2024
	Implementation Date for Notice/Description: 10/11/2024
	12_Anthem Blue Cross_UM_Medi-Cal_CoC_Denial_Letter_Templates	348 KB	11/20/2024
	Implementation Date for Notice/Description: 10/11/2024
	13_Anthem Blue Cross_UM_Medi-Cal_CoC_Expiration_Letter_Templates	395 KB	11/20/2024
	Implementation Date for Notice/Description: 10/11/2024
	002A_Anthem_Blue_Cross_UM and CLAIMS_CA_EAE_MLI_Nondiscrimination_01_23_Standard_Print	10063 KB	1/21/2025
	Implementation Date for Notice/Description: 01012025
	002B_Anthem_Blue_Cross_UM and CLAIMS_CA_EAE_MLI_Nondiscrimination_07_23_Large_Print	15309 KB	1/21/2025
	Implementation Date for Notice/Description: 01012025
	003B_Anthem_Blue_Cross_UM and CLAIMS_CA_EAE_Know_Your_Rights_Attachment_12_23_Large_Print	6088 KB	1/23/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross__UM_Medicare_NOMNC_English_01.01.25	38 KB	1/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross__UM_Medicare_NOMNC_Spanish_01.01.25	32 KB	1/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross__UM_Medicare_HMO_DENC_English_01.01.25	38 KB	1/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross__UM_Medicare_HMO_DENC_Spanish_01.01.25	27 KB	1/24/2025
	Implementation Date for Notice/Description: 01012025
	005A Anthem_Blue_Cross_UM_CA_EAE_State_Fair_Hearing_Attachments_08_23(2) (6)	485 KB	1/30/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_Chinese Simplified	37 KB	2/11/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2025_01_01_CHINESE_ (1)	51 KB	2/11/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2025_01_01_VIETNAMESE	50 KB	2/11/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_Notice_of_Refusal_ to_ Vacate_ a _Dismissal_2025_01_01_ENGLISH_	34 KB	2/12/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_Notice_of_Refusal_ to_ Vacate_ a _Dismissal_2025_01_01_SPANISH_	31 KB	2/12/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_Spanish	37 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_Chinese_Simplified_DSNP	33 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_Spanish_DSNP	37 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_English	37 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice_English_ DSNP	37 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_Detailed Notice of Discharge DND 12 24 ENGLISH	37 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_Detailed Notice of Discharge DND 12 24 SPANISH	35 KB	2/24/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2025_01_01_ENGLISH (2)	47 KB	2/26/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_Claims_Medicare_CL_CMS_IDN_ Notice of Denial of Payment_2025.01_ENGLISH	48 KB	2/26/2025
	Implementation Date for Notice/Description: 01012025
	001B_Anthem_Blue_Cross_UM and Claims_CA_EAE_Coverage_Dec_Ltr_02_24_Large_Print	61812 KB	2/27/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM and Claims_Medicare_MLI_Insert_Standard_01.01.23(1)	371 KB	3/28/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_Non-DSNP_English	37 KB	4/15/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_DSNP_English	37 KB	4/15/2025
	Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_Non-DSNP_Spanish	36 KB	4/15/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_DSNP_Spanish	36 KB	4/15/2025
	Implementation Date for Notice/Description: 01012025
	001A_Anthem__Blue__Cross_UM_and_Claims_CA_EAE_Coverage_Dec_Ltr_02_24_Standard	683 KB	4/21/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_Claims_Medicare_CL_CMS_IDN_Notice_of_Denial_of_Payment_2025_01_01_SPANISH_(2)	42 KB	4/21/2025
	Implementation Date for Notice/Description: 01012025
	Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2025_01_01_SPANISH_(2)	42 KB	4/21/2025
	Implementation Date for Notice/Description: 01012025
	004A_Anthem_Blue_Cross_UM-and _Claims_IMR_Forms_DMHC-03_11_Standard_Print	5868 KB	4/22/2025
	Implementation Date for Notice/Description: 01012025
	003A_Anthem_Blue_Cross_UM_and_CLAIMS_CA_EAE_Know_Your_Rights_Attachments_02_24_Standard_Print (5)	1730 KB	5/12/2025
	Implementation Date for Notice/Description: 01012025
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.