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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
HICE posts whatever templates have been uploaded by participating health plans. Please contact the health plans directly for any templates not available on the HICE website. To receive broadcast messages when letter templates are added/updated by participating health 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 open category Blue Shield of California
     Click to open category Blue Shield of California Promise Health Plan
     Click to open category Brand New Day
     Click to close category Click to Download All Documents in Subfolder Cigna
       File   Upload   Review
  Title     Size   Date   Date
  Cigna_Claims_Commercial_Denial_Letter_6.23.2017   1167 KB   7/11/2017   7/7/2020
  Cigna_Claims_Commercial_ER_Denial_Letter_6.23.2017   1167 KB   7/11/2017   7/7/2020
  Cigna_UM_Comm_LAP_Option 1_Non-Discrimination Language   197 KB   1/4/2018   1/4/2021
  Cigna_UM_Comm_LAP_Option 1_Notice_of_Translation_2017   607 KB   1/4/2018   1/4/2021
  Cigna_UM_Comm_LAP_Option 2_Approval_Outpatient_12-2019   1136 KB   1/30/2020   
  Cigna_UM_Comm_LAP_Option 2_Denial_Notice_03-2021   1164 KB   3/16/2021   
  Cigna_UM_Comm_LAP_Option 2_Notice_of_Non-Coverage_Termination_of_Services_(NONCTOS)_043-2...   1160 KB   3/16/2021   
  Cigna_UM_Comm_LAP_Option 2_Spec_Term_02-2020   1260 KB   5/5/2020   
     Click to open category Health Net
Health Net Required Attachments - the Health Net Nondiscrimination Notice (NDN) and Multi Language Insert (MLI)/Taglines must be included in all Cal MediConnect (CMC) member letters. Use the Health Net Cal MediConnect English NDN and MLI for letters sent in English or one of the Translated Letters. In addition to the NDN and MLI, the Language Disclaimer & State Hearing Form must be attached to the HN_CMC_Medicaid_NOA_Deferral_LA_SD_County letter.
     Click to open category Humana
     Click to open category Inter Valley Health Plan
     Click to open category Sharp Health Plan
     Click to open category Wellcare 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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