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
		File	Upload	Review
	Title	Size	Date	Date
	03-24 CA ONLY ME03 14 day Extension for Expedited	50 KB	3/28/2024
	Implementation Date for Notice/Description: 2024
	03-24 CA ONLY_AETNA ME12_Medicare expedited denial	43 KB	3/28/2024
	Implementation Date for Notice/Description: 2024
	05-24 CA ME04_Medicare_14_day_ext_for_standard	45 KB	5/14/2024
	Implementation Date for Notice/Description: 2024
	05-24 CA Specialist Term Letter	57 KB	5/3/2024
	Implementation Date for Notice/Description: 2024
	05-24 Multi Language Insert	31 KB	5/3/2024
	Implementation Date for Notice/Description: 2024
	12-20_CA_ONLY AETNA_UM_MA_ME09_Notice of Medicare Non Coverage_Spanish	89 KB	1/7/2021	1/2/2024

	12-20_CA_ONLY_AETNA_UM_MA_DENC AETNA ME11_ (Spanish version)	93 KB	1/7/2021	1/2/2024

	1224 CA CMS DSNP NDN_Taglines	38 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CA CMS NDN_taglines	30 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME09 - NOMNC CA	64 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME09 - NOMNC CA DSNP	59 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME11 - DENC CA	61 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME11 - DENC CA DSNP	64 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME13 - NDMC CA	82 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME13 - NDMC CA DSNP	81 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME17_Notice_of_Dismissal_of_Pre-Service_OD_Request CA	76 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	1224 CMS ME17_Notice_of_Dismissal_of_Pre-Service_OD_Request CA DSNP	79 KB	12/12/2024
	Implementation Date for Notice/Description: 1/1/25
	Aetna Approval Feb 2021 FI California Clean	100 KB	3/7/2024
	Implementation Date for Notice/Description: 2023
	Aetna CA Comm Service Denial Notice (CSDN)_rev 10.2023	71 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	Aetna CA ICE_Carve_Out_Situations_(COS)_Commercial_02-18	52 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	Aetna CA ONLY _Provider Leaving Generic_Retraction_Letter 0420	48 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	Aetna CA ONLY Provider Leaving Specialist_PCP_Combined_Letter_0320	50 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	Aetna Pend Letter clinical 2021	205 KB	1/11/2023
	Implementation Date for Notice/Description: 2021
	Aetna_Comm_Claim_Member_Denial_Ltr_Final 11.29.2024	93 KB	12/19/2024

	Aetna_UM_Comm_LAP_Option 2_CA Commercial Non-Discrimination Notice 0218	16 KB	2/21/2018	2/20/2024

	Aetna_UM_Comm_LAP_Option 2_CA State Taglines 0218	29 KB	2/21/2018	2/20/2024

	CMS CA ONLY_ AETNA ME07 Medicare Approval Letter_10-23	47 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	CMS CA ONLY_Provider_Retraction_Medicare_Member_NR_0009_8530a_1020	47 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	CMS_10003_NDMCP_ Part B_SPANISH (IDN)_08-23	53 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
	CMS_10003_NDMCP_ Medical Services_SPANISH_(IDN)_08-23	53 KB	3/11/2024
	Implementation Date for Notice/Description: 2023
Anthem Blue Cross
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.