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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 open category Cigna
     Click to close category Click to Download All Documents in Subfolder 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.
       File   Upload   Review
  Title     Size   Date   Date
  Health_Net_CA_UM_MA_Dismissal_Withdrawal_of Cvrg_04082022   65 KB   6/11/2022   
  Health_Net_CA_UM_MA_DSNP_Dismissal_Withdrawal_of_Cvrg 5.20.2022   65 KB   6/11/2022   
  Health_Net_CA_UM_MA_HMO_Approval_Template_Rev.10.2017   36 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Carve_Out_Notice_eff1.1.2017   27 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Detailed_Explanation_of_Non-Coverage_DENC_eff1.1.2017   33 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Detailed_Notice_of_Discharge_DND_eff_3.18.2021   29 KB   3/26/2021   
  Health_Net_CA_UM_MA_HMO_Does_Not_Meet_Reopen_Criteria_eff_1.1.2017   29 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Notice_of_MA_Non_Cov_NOMNC_eff_042018   48 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Notice_of_Reinstatement_of_Cov_eff_1.1.2017   24 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_Notice_Right_to_an_Expedited_Grievance_NREG_eff1.1.2017   25 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMO_PPG_Specialty_and_Ancillary_Term_Notice_eff_1.1.2017   25 KB   1/11/2019   3/22/2022
  Health_Net_CA_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_PartB_Eff.4.2020   45 KB   4/23/2020   
  Health_Net_CA_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_withoutPartB_Eff.4.2020   43 KB   4/23/2020   
  Health_Net_CA_UM_MA_NDN_Taglines_NonDel 2021   782 KB   9/2/2021   
Implementation Date for Notice/Description: The Health Net Non-Discrimination Notice (NDN) for download and print; not online use.
  Health_Net_CHI_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_PartB_Eff._4.2020   45 KB   4/23/2020   
  Health_Net_CHI_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_withoutPartB_Eff.4.2020   44 KB   4/23/2020   
  Health_Net_SPN_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_PartB_Eff.4.2020   45 KB   4/23/2020   
  Health_Net_SPN_UM_MA_HMOSNP_Integrated_Denial_Notice_IDN_NDMC_withoutPartB_Eff.4.2020   42 KB   4/23/2020   
  Health_Net_UM_CMC_Letter - ARABIC   448 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - ARMENIAN   396 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - CAMBODIAN_KHMER   479 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - CHINESE   543 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - ENGLISH   774 KB   6/17/2022   
  Health_Net_UM_CMC_Letter - FARSI   376 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - KOREAN   591 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - RUSSIAN   414 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - SPANISH   389 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - TAGALOG   356 KB   5/27/2022   8/6/2022
  Health_Net_UM_CMC_Letter - VIETNAMESE   451 KB   5/27/2022   8/6/2022
  Health_Net_UM_Comm_LAP_Option 1_NDN_TL_DMHC_NotDel_FLY021239EW00 EFF 6.2018   2761 KB   12/21/2020   
  Health_Net_UM_Comm_LAP_Option 2_CSDN_Carve_Out_Situations_(COS)_eff 1.1.2017   22 KB   4/27/2020   
  Health_Net_UM_Comm_LAP_Option 2_CSDN_Delay-Extension_eff 1.1.2017   25 KB   4/27/2020   
  Health_Net_UM_Comm_LAP_Option 2_CSDN_Denial_V2_eff 7.23.2021   27 KB   7/23/2021   
  Health_Net_UM_Comm_LAP_Option 2_Notice_of_Non-Coverage_Term_of_Services_(NONCTOS)_PPACA_eff 1.1.2017   31 KB   4/27/2020   
  Health_Net_UM_Comm_LAP_Option 2_Refusal_To_Transfer_(RTT)_PPACA_eff 1.1.2017   31 KB   4/27/2020   
  Health_Net_UM_Comm_LAP_Option 2_SNF_Exhaustion_of_Benefits_(SNFEXH)_PPACA_eff1.1.17   29 KB   4/27/2020   
  HN_Claims_CMC_2020_PrecludedNonDel_ARB_Eff.9.2020   471 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_ARM_Eff.9.2020   554 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_CHI_Eff.9.2020   496 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_CMB_Eff.9.2020   1004 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_ENG_Eff.9.2020   502 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_FAR_Eff.9.2020   465 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_KOR_Eff.9.2020   490 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_RUS_Eff.9.2020   467 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_SPN_Eff.9.2020   486 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_TAG_Eff.9.2020   516 KB   10/1/2021   
  HN_Claims_CMC_2020_PrecludedNonDel_VIE_Eff.9.2020   504 KB   10/1/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_ARABIC_1-1-22   1820 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_ARMENIAN_1-1-22   2491 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_CAMBODIAN_1-1-22   6898 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_CHINESE_1-1-22   2889 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_ENGLISH_1-1-22   1225 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_FARSI_1-1-22   2346 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_KOREAN_1-1-22   2593 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_RUSSIAN_1-1-22   2708 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_SPANISH_1-1-22   2637 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_TAGALOG_1-1-22   2829 KB   12/21/2021   
  HN_Claims_CMC_2022_IDN_NonDel_for_LAP_VIETNAMESE_1-1-22   2952 KB   12/21/2021   
  HN_Claims_Commercial_Denial_Letter_HCR_1-1-2017   2815 KB   8/26/2021   
  HN_Claims_Commercial_Denial_Letter_HCR_ER_1-1-2017   2853 KB   8/26/2021   
  HN_Claims_Medicare_2019_MA_PreclusionMember_NonDel_Eff.3.2019   310 KB   9/1/2021   
  HN_Claims_Medicare_CHI_HMO_PPO_CMS_IDN_Claims_NDP_NonDel_Eff.4.2020   380 KB   9/1/2021   
  HN_Claims_Medicare_ENG_HMO_PPO_CMS_IDN_Claims_NDP_NonDel_Eff.4.2020   429 KB   9/1/2021   
  HN_Claims_Medicare_KOR_HMO_PPO_CMS_IDN_Claims_NDP_NonDel_Eff.4.2020   3542 KB   9/1/2021   
  HN_Claims_Medicare_SPN_HMO_PPO_CMS_IDN_Claims_NDP_NonDel_Eff.4.2020   428 KB   9/1/2021   
  HN_Claims_Medicare_VIE_HMO_PPO_CMS_IDN_Claims_NDP_NonDel_Eff.4.2020   3542 KB   9/1/2021   
  HN_Req Attachment_UM_CMC_ Disclaimer_FLY014402EL00_LA-SD   282 KB   7/18/2019   7/19/2022
  HN_Req Attachment_UM_CMC_ Hearing Form   30 KB   7/18/2019   7/19/2022
  HN_Req Attachment_UM_CMC_FLY048882EW00_CMC_NonDel_NDN_MLI_English   1177 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054154AH00_CMC_NonDel_NDN_MLI_Arabic   1559 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054155MH00_CMC_NonDel_NDN_MLI_Armenian   1665 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054156DH00_CMC_NonDel_NDN_MLI_Khmer   1652 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054157CH00_CMC_NonDel_NDN_MLI_Chinese   1791 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054158FH00_CMC_NonDel_NDN_MLI_Farsi   1543 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054159KH00_CMC_NonDel_NDN_MLI_Korean   1811 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054160RH00_CMC_NonDel_NDN_MLI_Russian   1913 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054161SH00_CMC_NonDel_NDN_MLI_Spanish   1939 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054162TH00_CMC_NonDel_NDN_MLI_Tagalog   2040 KB   9/29/2021   
  HN_Req Attachment_UM_CMC_FLY054163VH00_CMC_NonDel_NDN_MLI_Vietnamese   2030 KB   9/29/2021   
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_ARABIC   1822 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_ARMENIAN   6243 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_CAMBODIAN_KHMER   6535 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_CHINESE   2890 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_ENGLISH   1227 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_FARSI   2347 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_KOREAN   2594 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_RUSSIAN   2713 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_SPANISH   2640 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_TAGALOG   2832 KB   12/21/2021   8/6/2022
  HN_UM_CMC_2022_IDN_NonDel_for_LAP_VIETNAMESE   2956 KB   12/21/2021   8/6/2022
  HN_UM_Medi-Cal_NOA_YourRights_ARABIC   244 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_ARMENIAN   246 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_CAMBODIAN   242 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_CHINESE   231 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_ENGLISH   250 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_FARSI   238 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_HMONG   264 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_KOREAN   249 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_RUSSIAN   242 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_SPANISH   234 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_TAGALOG   236 KB   3/11/2022   
  HN_UM_Medi-Cal_NOA_YourRights_VIETNAMESE   239 KB   4/12/2022   
  TEST    14 KB   9/16/2022   
Implementation Date for Notice/Description: 10-16-2022
  TEST_UM_HN MediCal_Letters_09262022   16850 KB   9/16/2022   
Implementation Date for Notice/Description: 10-16-2022
  TEST_UM_HN MediCal_Letters_09262022   16850 KB   9/16/2022   
Implementation Date for Notice/Description: 10-16-2022
     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

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