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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 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 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 close category Click to Download All Documents in Subfolder Inter Valley Health Plan
       File   Upload   Review
  Title     Size   Date   Date
  Inter_Valley_Health_Plan_UM_MA_Detailed_Notice_of_Discharge_DND_1-26-2021   28 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Detailed_Notice_of_Discharge_DND_1-26-2021_SP   24 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Expedited_Criteria_Not_Met_1-26-2021   37 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Explanation_of_Non-Coverage_DENC_1-26-2021   26 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Explanation_of_Non-Coverage_DENC_1-26-2021_SP   34 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Extension_Standard_&_Expedited_1-26-2021   47 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Informational_Carve_Out_1-26-2021   40 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Integrated_Denial_Notice_CMS_10003_1-26-2021   47 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Integrated_Denial_Notice_CMS_10003_1-26-2021_SP   45 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Medicare_Outpatient_Observation_Notice_MOON_1-26-2021   42 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Medicare_Outpatient_Observation_Notice_MOON_1-26-2021_SP   32 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Multi Language SP_2020   416 KB   4/9/2020   
  Inter_Valley_Health_Plan_UM_MA_Multi Language_2020   411 KB   4/9/2020   
  Inter_Valley_Health_Plan_UM_MA_Notice_of_Medicare_Non-Coverage_NOMNC_1-26-2021   57 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Notice_of_Medicare_Non-Coverage_NOMNC_1-26-2021_SP   56 KB   3/3/2021   
  Inter_Valley_Health_Plan_UM_MA_Part C_Notice_of_Dismissal_of_Appeal Request_1-31-2022   37 KB   2/25/2022   8/1/2022
  Inter_Valley_Health_Plan_UM_MA_Part C_Notice_of_Dismissal_of_Coverage_Request_5-24-2022   38 KB   5/26/2022   
  Inter_Valley_Health_Plan_UM_MA_Reinstatement_of_Coverage_1-26-2021   33 KB   3/3/2021   
     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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