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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 close category Click to Download All Documents in Subfolder Anthem Blue Cross
       File   Upload   Review
  Title     Size   Date   Date
  01_Anthem Blue Cross_UM_Medi-Cal_INSTRUCTIONS FOR USING NOTICES OF ACTION (NOA)_rev 02.2022   142 KB   4/6/2022   
  02_Anthem_Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_All_Languages   14242 KB   4/6/2022   
  03_Anthem Blue Cross_UM_Medi-Cal_Your Rights Attachments   674 KB   4/6/2022   
  04_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State Fair Hearing Attachments   6626 KB   4/6/2022   
  05_Anthem_Blue_Cross_UM_Medi-Cal_NOA_DENIAL_Templates   3803 KB   4/6/2022   
  06_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Modify_Templates   6953 KB   4/6/2022   
  07_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Carve-out_Templates   420 KB   4/6/2022   
  08_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Spec_Term_Letter_Template   3185 KB   4/6/2022   
  09_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Delay_Templates   253 KB   4/6/2022   
  Anthem_Blue_Cross_UM_Comm_LAP_Option 2_ Pended_Notification_Template_rev 5.16.17   114 KB   5/26/2017   5/26/2020
  Anthem_Blue_Cross_UM_Comm_LAP_Option 2_Authorization_Notification Template_rev 5.16.17   163 KB   7/12/2017   7/14/2020
  Anthem_Blue_Cross_UM_Comm_LAP_Option 2_CA Only_Delegate COM Specialist Term Template_10.2020   35 KB   11/11/2020   
  Anthem_Blue_Cross_UM_Comm_LAP_Option 2_Carve Out Letter Template_rev 5.16.17   164 KB   5/26/2017   5/26/2020
  Anthem_Blue_Cross_UM_Comm_LAP_Option 2_Service_Denial_Notice (CSDN)_rev 09.07.21(clean)   117 KB   9/7/2021   
  Anthem_Blue_Cross_UM_MA_CA Only_Delegate MCR Specialist Term Template_10.2020   62 KB   11/11/2020   
  Anthem_Blue_Cross_UM_MA_CA_Medicare_HMO_Dismissal of Prior Auth Request_Notice   37 KB   2/22/2022   
  Anthem_Blue_Cross_UM_MA_Carve_Out_Situation_2.27.12_with_Nondiscrimination_Not...   47 KB   3/9/2018   3/8/2021
  Anthem_Blue_Cross_UM_MA_HMO_Extension_Standard_Expedited_Review_Ltr_ w/ ND_Notice_and_LEP_11.16   52 KB   12/4/2017   12/15/2020
  Anthem_Blue_Cross_UM_MA_Integrated_Denial_Notice_NDMC_CHINESE_eff 01.01.21   3377 KB   12/21/2020   
  Anthem_Blue_Cross_UM_MA_Integrated_Denial_Notice_NDMC_eff 01.01.21   60 KB   12/21/2020   
  Anthem_Blue_Cross_UM_MA_Integrated_Denial_Notice_NDMC_SPANISH_eff 01.01.21   61 KB   12/21/2020   
  Anthem_Blue_Cross_UM_MA_Medicare_HMO_DENC_9.16_with_ND_Notice_and_LEP_11.16.17   90 KB   12/4/2017   12/15/2020
  Anthem_Blue_Cross_UM_MA_Medicare_HMO_UM_Approval_Ltr_with_ND_Notice_and_LEP_11.16.17   51 KB   12/4/2017   12/15/2020
  Anthem_Blue_Cross_UM_MA_Nondiscrimination_LEP_CA   512 KB   3/20/2020   
  Anthem_Blue_Cross_UM_MA_Notice_of_Reinstatement_of_Coverage_02.27.12_with_Nond...   47 KB   3/9/2018   3/8/2021
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_ARABIC   7178 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_ARMENIAN   6324 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_CHINESE   5434 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_ENGLISH   542 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_FARSI   7018 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_KHMER   5672 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_KOREAN   4610 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_RUSSIAN   7131 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_SPANISH   9513 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_TAGALOG   9603 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_LA County_VIETNAMESE   9722 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_SC County_CHINESE   5441 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_SC County_ENGLISH   538 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_SC County_SPANISH   9539 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_SC County_TAGALOG   9621 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP IDN_IMR Form_NonD_eff 01.01.22_SC County_VIETNAMESE   9756 KB   11/30/2021   8/6/2022
  Anthem_Blue_Cross_UM_MMP_Nondiscrimination_LEP Notices   667 KB   3/12/2019   3/10/2022
     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 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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