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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
Cigna
Clever Care Health Plan
		File	Upload	Review
	Title	Size	Date	Date
	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_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
	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_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
	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_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_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
	DENC_Detailed Explanation of NonCoverage_2025_CCHP	217 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	DENC_Detailed Explanation of NonCoverage_2025_CCHP-Chinese	211 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	DENC_Detailed Explanation of NonCoverage_2025_CCHP-Korean	178 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	DENC_Detailed Explanation of NonCoverage_2025_CCHP-Spanish	212 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	DENC_Detailed Explanation of NonCoverage_2025_CCHP-Vietnamese	222 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	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
	Model Notice of Right to Expedited Grievance_Part C_2025_CCHP	207 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Model Notice of Right to Expedited Grievance_Part C_2025_CCHP-Chinese	208 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Model Notice of Right to Expedited Grievance_Part C_2025_CCHP-Korean	207 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Model Notice of Right to Expedited Grievance_Part C_2025_CCHP-Spanish	203 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Model Notice of Right to Expedited Grievance_Part C_2025_CCHP-Vietnamese	213 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Coverage_UM_2025_CCHP_FINAL	228 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Coverage_UM_2025_CCHP_FINAL-Chinese	221 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Coverage_UM_2025_CCHP_FINAL-Korean	220 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Coverage_UM_2025_CCHP_FINAL-Spanish	215 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Coverage_UM_2025_CCHP_FINAL-Vietnamese	228 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Payment_Claims_2025_CCHP_FINAL	221 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Payment_Claims_2025_CCHP_FINAL-Chinese	217 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Payment_Claims_2025_CCHP_FINAL-Korean	224 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Payment_Claims_2025_CCHP_FINAL-Spanish	216 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NDMCP_Notice of Denial of Payment_Claims_2025_CCHP_FINAL-Vietnamese	227 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NOMNC_Notice of Medicare Non-Coverage_2025_CCHP	216 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NOMNC_Notice of Medicare Non-Coverage_2025_CCHP-Chinese	211 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NOMNC_Notice of Medicare Non-Coverage_2025_CCHP-Korean	216 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NOMNC_Notice of Medicare Non-Coverage_2025_CCHP-Spanish	211 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	NOMNC_Notice of Medicare Non-Coverage_2025_CCHP-Vietnamese	219 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Notice of Dismissal of Coverage Request_2025_CCHP	216 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Notice of Dismissal of Coverage Request_2025_CCHP-Chinese	213 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Notice of Dismissal of Coverage Request_2025_CCHP-Korean	216 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Notice of Dismissal of Coverage Request_2025_CCHP-Spanish	212 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
	Notice of Dismissal of Coverage Request_2025_CCHP-Vietnamese	218 KB	2/13/2025
	Implementation Date for Notice/Description: 03/31/2025
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.