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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

 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 open category Clever Care Health Plan
     Click to open category Elite Health Plan
     Click to close category Click to Download All Documents in Subfolder Health Net
       File   Upload   Review
  Title     Size   Date   Date
  HN_UM_COMM_Carve-Out   18 KB   4/16/2026   
  HN_UM_COMM_Delay   19 KB   4/16/2026   
  HN_UM_H0562 MCR_Carve Out   23 KB   4/16/2026   
  HN_UM_COMM_Denial   28 KB   4/16/2026   
  HN_UM_COMM_Community Care   28 KB   4/16/2026   
  HN_UM_H0562 MCR_Approval   32 KB   4/16/2026   
  CVH_UM_H3561 007 MCR EAE DSNP_DENC   135 KB   4/16/2026   
  CHPIV_UM_MCAL_Carve-Out   145 KB   4/16/2026   
  CHPIV_UM_MCAL_Terminate   149 KB   4/16/2026   
  HN_UM_H0562 MCR_DENC   178 KB   4/16/2026   
  CHPIV_UM_MCAL_Modify   184 KB   4/16/2026   
  CHPIV_UM_MCAL_Delay   184 KB   4/16/2026   
  HN_UM_H0562 MCR_NOMNC   211 KB   4/16/2026   
  HN_UM_H0562 MCR_Denial   238 KB   4/16/2026   
  HN_Claims_H0562 MCR_Denial   253 KB   4/16/2026   
  CHPIV_UM_MCAL_Denial   253 KB   4/16/2026   
  CVH_UM_H3561 007 MCR EAE DSNP_Denial   264 KB   4/16/2026   
Implementation Date for Notice/Description: English: 3/9/2026; Translations: 5/7/2026
  CVH_Claims_H3561 007 MCR EAE DSNP_Denial   299 KB   4/16/2026   
Implementation Date for Notice/Description: English: 3/9/2026; Translations: 4/27/2026
  HN_UM_H3561 001 009 MCR Non EAE DSNP_DENC   340 KB   4/16/2026   
  CVH_UM_H3561 007 MCR EAE DSNP_NOMNC   344 KB   4/16/2026   
  HN_UM_H3561 008 MCR EAE DSNP_DENC   350 KB   4/16/2026   
  CVH_UM_MCAL_Terminate   385 KB   4/16/2026   
  CVH_UM_MCAL_Carve Out   396 KB   4/16/2026   
  HN_UM_MCAL_Terminate   426 KB   4/16/2026   
  HN_UM_MCAL_Carve-Out   432 KB   4/16/2026   
  HN_UM_H3561 008 MCR EAE DSNP_NOMNC   440 KB   4/16/2026   
  HN_UM_H3561 001 009 MCR Non EAE DSNP_NOMNC   477 KB   4/16/2026   
  CVH_Claims & UM_H3561 007 MCR EAE DSNP_Inserts   498 KB   4/16/2026   
  HN_Claims_H3561 001 009 MCR Non EAE DSNP_Denial   552 KB   4/16/2026   
  CVH_UM_MCAL_Delay   573 KB   4/16/2026   
  CVH_UM_MCAL_Denial   573 KB   4/16/2026   
  CVH_UM_MCAL_Modify   583 KB   4/16/2026   
  HN_UM_MCAL_Delay   625 KB   4/16/2026   
  HN_UM_MCAL_Denial   626 KB   4/16/2026   
  HN_UM_MCAL_Modify   638 KB   4/16/2026   
  HN_Claims & UM_H0562 MCR_Inserts   695 KB   4/16/2026   
Implementation Date for Notice/Description: NOAs: 3/5/2026
  HN_Claims_H3561 008 MCR EAE DSNP_Denial   724 KB   4/16/2026   
Implementation Date for Notice/Description: English: 3/9/2026; Translations: 4/27/2026
  HN_UM_H3561 008 MCR EAE DSNP_Approval   1161 KB   4/16/2026   
  HN_Claims & UM_H3561 008 MCR EAE DSNP_Inserts   1488 KB   4/16/2026   
  HN_Claims & UM_H3561 001 009 MCR Non EAE DSNP_Inserts   1489 KB   4/16/2026   
  CVH_UM_H3561 007_MCR EAE DSNP_Approval   1523 KB   4/16/2026   
  HN_UM_COMM_Insert   2513 KB   4/16/2026   
  HN_Claims_COMM_Insert   2537 KB   4/16/2026   
  HN_UM_H3561 001 009 MCR Non EAE DSNP_Denial   4722 KB   4/16/2026   
  HN_Claims_COMM_Denial   5179 KB   4/16/2026   
  CHPIV_UM_MCAL_Inserts   7268 KB   4/16/2026   
  CVH_UM_MCAL_Inserts   7776 KB   4/16/2026   
  HN_UM_MCAL_Inserts   7846 KB   4/16/2026   
  HN_UM_H3561 008 MCR EAE DSNP_Denial   19801 KB   4/16/2026   
Implementation Date for Notice/Description: English: 3/9/2026; Translations: 5/7/2026
     Click to open category Sharp Health Plan
     Click to open category Test

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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