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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 close category Click to Download All Documents in Subfolder Brand New Day
       File   Upload   Review
  Title     Size   Date   Date
  BRAND NEW DAY_Claims_Medicare_Notice of Denial of Medical Coverage or Payment_NDMCP_ENG   62 KB   3/19/2020   
  BRAND NEW DAY_Claims_Medicare_Notice of Denial of Medical Coverage or Payment_NDMCP_SPAN   62 KB   3/19/2020   
  BRAND_NEW_DAY_UM_MA_Authorization_Letter_ENG   21 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Authorization_Letter_SP   25 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_CarvedOut_Letter_ENG   33 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Det_Exp_of_Non-Cov_(DENC)_ENG   48 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Det_Exp_of_Non-Cov_(DENC)_SP   47 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Does_Not_Meet_Reopen-Criteria_ENG   34 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Exp_Criteria_Not_Met_ENG   32 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Ext_Needed_for_Additional_Information_ENG   34 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_Denial_of_Medical_Coverage_or_Payment_NDMCP_ENG_V2   48 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_Denial_of_Medical_Coverage_or_Payment_NDMCP_SPAN_V2   45 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_MA_Non_Cov_NOMNC_ENG   54 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_Non-Discrimination_ENG   76 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_Non-Discrimination_SP   77 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Notice_of_Non_Cov_NOMNC_SPAN   55 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Reinstatement_of_Coverage_ENG   31 KB   4/22/2020   
  BRAND_NEW_DAY_UM_MA_Specialty_and_ANC_Term_Notice_ENG   159 KB   4/22/2020   
     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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