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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 open category Aetna
     Click to open category Anthem Blue Cross
     Click to close category Click to Download All Documents in Subfolder Cigna
       File   Upload   Review
  Title     Size   Date   Date
  Cigna_Claims_Commercial_ER_MemberDenialNotice_10.2023   448 KB   10/24/2023   
Implementation Date for Notice/Description: 10/2023
  Cigna_Claims_Commercial_MemberDenialNotice_10.2023   454 KB   10/24/2023   
Implementation Date for Notice/Description: 10/2023
  Cigna_UM_Comm_LAP_Option 1_Non-Discrimination Language 11_2023   514 KB   11/16/2023   
Implementation Date for Notice/Description: 12/16/2023
  Cigna_UM_Comm_LAP_Option 2_Denial_Notice_8-2024   668 KB   8/28/2024   
Implementation Date for Notice/Description: 10/01/2024
  CIgna_UM_Comm_LAP_Option 2_Notice of Non-Coverage-SNF Exhaustion of Benefits_8-2024   1171 KB   8/28/2024   
Implementation Date for Notice/Description: 10/01/2024
  Cigna_UM_Comm_LAP_Option 2_Notice_of_Non-Coverage_Termination_of_Services_(NONCTOS)_8-2024   664 KB   8/28/2024   
Implementation Date for Notice/Description: 10/01/2024
  Cigna_UM_Comm_LAP_Option 2_Refusal to Transfer_8-2024   1171 KB   8/28/2024   
Implementation Date for Notice/Description: 10/01/2024
  HICE_Cigna_Approval_Inpatient 09-2024   19 KB   9/9/2024   
Implementation Date for Notice/Description: 10/01/2024
  HICE_Cigna_Approval_Outpatient_09-2024   640 KB   9/9/2024   
Implementation Date for Notice/Description: 10/01/2024
  ICE_Cigna_Spec_Term_11-2023   882 KB   11/16/2023   
Implementation Date for Notice/Description: 12/16/2023
     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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