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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 close category Click to Download All Documents in Subfolder Aetna
       File   Upload   Review
  Title     Size   Date   Date
  03-23 CMS-10003_IDN-NDMCP_ Medical Services   55 KB   5/5/2023   
  03-23 CMS-10003_IDN-NDMCP_ Part B drug   55 KB   5/5/2023   
  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
  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_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
  CA DSNP Notice Template + Taglines-0923   43 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CA ONLY AETNA ME09_(NOMNC) Notice of Medicare Non-Coverage_10-20    95 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CA ONLY DENC_10-20    41 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CMS CA ONLY_ AETNA ME07 Medicare Approval Letter_10-23    47 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CMS CA ONLY_AETNA ME03_Medicare_14_day_ext_for_expedited_10-20   86 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CMS CA ONLY_AETNA ME04_Medicare_14_day_ext_for_standard_10-20    77 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CMS CA ONLY_AETNA ME12_Medicare expedited denial_10-20    77 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
  CMS CA ONLY_PROVIDER No Longer In Network_Medicare_Member_NR_0009_10122_1020    41 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
  ME17-Aetna-Enrollment Source ID 42 (Dismissal)_06-23    52 KB   3/11/2024   
Implementation Date for Notice/Description: 2023
     Click to open category Anthem Blue Cross
     Click to open category Cigna
     Click to open category Clever Care Health Plan
     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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