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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
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).
     Click to open category Aetna
     Click to open category Anthem Blue Cross
     Click to open category Cigna
     Click to close category Click to Download All Documents in Subfolder Clever Care Health Plan
       File   Upload   Review
  Title     Size   Date   Date
  Clever Care_UM_Medicare_HMO_Carve Out_03-31-23_Chinese   419 KB   4/5/2023   
  Clever Care_UM_Medicare_HMO_Carve Out_03-31-23_English   968 KB   4/5/2023   
  Clever Care_UM_Medicare_HMO_Carve Out_03-31-23_Korean   1347 KB   4/5/2023   
  Clever Care_UM_Medicare_HMO_Carve Out_03-31-23_Spanish   1512 KB   4/5/2023   
  Clever Care_UM_Medicare_HMO_Carve Out_03-31-23_Vietnamese   1126 KB   4/5/2023   
  Clever Care_UM_Medicare_HMO_DND_05-02-23_Chinese   426 KB   5/2/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_DND_05-02-23_English   379 KB   5/2/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_DND_05-02-23_Korean   392 KB   5/2/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_DND_05-02-23_Spanish   373 KB   5/2/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_DND_05-02-23_Vietnamese   389 KB   5/2/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Claims_Medicare_HMO_IDN (NDMCP)_05-24-23_Chinese   429 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Claims_Medicare_HMO_IDN (NDMCP)_05-24-23_English   386 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Claims_Medicare_HMO_IDN (NDMCP)_05-24-23_Korean   397 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Claims_Medicare_HMO_IDN (NDMCP)_05-24-23_Spanish   393 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Claims_Medicare_HMO_IDN (NDMCP)_05-24-23_Vietnamese   393 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_IDN (NDMCP)_05-24-23_Chinese   434 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_IDN (NDMCP)_05-24-23_English   394 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_IDN (NDMCP)_05-24-23_Korean   397 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_IDN (NDMCP)_05-24-23_Spanish   393 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_IDN (NDMCP)_05-24-23_Vietnamese   396 KB   5/24/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Medicare_HMO_DENC_03-31-23_Chinese   1202 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Medicare_HMO_DENC_03-31-23_English   1081 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Medicare_HMO_DENC_03-31-23_Korean   1140 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Medicare_HMO_DENC_03-31-23_Spanish   1083 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_Medicare_HMO_DENC_03-31-23_Vietnamese   1125 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Notice_of_Reinstatement_03-31-23_Chinese   413 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Notice_of_Reinstatement_03-31-23_English   365 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Notice_of_Reinstatement_03-31-23_Korean   379 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Notice_of_Reinstatement_03-31-23_Spanish   376 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Notice_of_Reinstatement_03-31-23_Vietnamese   376 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Pre-Service_Notice_Withdrawal_03-31-23_Chinese   421 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Pre-Service_Notice_Withdrawal_03-31-23_English   374 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Pre-Service_Notice_Withdrawal_03-31-23_Korean   386 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Pre-Service_Notice_Withdrawal_03-31-23_Spanish   377 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Pre-Service_Notice_Withdrawal_03-31-23_Vietnamese   384 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Approval_Letter_03-31-23_Chinese   484 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Approval_Letter_03-31-23_English   439 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Approval_Letter_03-31-23_Korean   450 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Approval_Letter_03-31-23_Spanish   441 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  Clever Care_UM_Medicare_HMO_Approval_Letter_03-31-23_Vietnamese   448 KB   6/27/2023   
Implementation Date for Notice/Description: 05/03/2023
  M10003-NDN-MLI-EN-1023 - ENGLISH   208 KB   4/8/2024   
Implementation Date for Notice/Description: 10/01/2023
  M10003-NDN-MLI-ES-1023 - SPANISH   207 KB   4/8/2024   
Implementation Date for Notice/Description: 10/01/2023
  M10003-NDN-MLI-KO-1023 - KOREAN   208 KB   4/8/2024   
Implementation Date for Notice/Description: 10/01/2023
  M10003-NDN-MLI-VI-1023 - VIETNAMESE   213 KB   4/8/2024   
Implementation Date for Notice/Description: 10/01/2023
  M10003-NDN-MLI-ZH-1023 - CHINESE   241 KB   4/8/2024   
Implementation Date for Notice/Description: 10/01/2023
  Clever Care_MA Provider Termination Notice model document_03.26.24_English_TEMPLATE   36 KB   4/19/2024   
Implementation Date for Notice/Description: 03/26/2024
  Clever Care_MA Provider Termination Notice model document_03.26.24-Chinese_TEMPLATE   35 KB   4/19/2024   
Implementation Date for Notice/Description: 03/26/2024
  Clever Care_MA Provider Termination Notice model document_03.26.24-Korean_TEMPLATE   35 KB   4/19/2024   
Implementation Date for Notice/Description: 03/26/2024
  Clever Care_MA Provider Termination Notice model document_03.26.24-Spanish_TEMPLATE   35 KB   4/19/2024   
Implementation Date for Notice/Description: 03/26/2024
  Clever Care_MA Provider Termination Notice model document_03.26.24-Vietnamese_TEMPLATE   36 KB   4/19/2024   
Implementation Date for Notice/Description: 03/26/2024
     Click to open category Health Net
     Click to open category 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.

   


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