Health Industry Collaboration Effort

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Administrative & Organizational Folders Agency Resources APPROVED HICE DOCUMENTS Current Annual Conference Information Current Training Workshops and Materials Health Plan Specific Letter Templates HICE Team Folders Working Documents Past Annual Meeting Information Teams Not Currently Active

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
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
	03-23 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
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.