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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 close category Click to Download All Documents in Subfolder Blue Shield of California
       File   Upload   Review
  Title     Size   Date   Date
  Blue_Shield_of_California_UM_Comm_LAP_Option 1_Non-discrimination 3.25.2020   898 KB   3/27/2020   
  Blue_Shield_of_California_UM_Comm_LAP_Option 2_CSDN 2.2021   55 KB   3/1/2021   
  Blue_Shield_of_California_UM_Comm_LAP_Option 2_Modification 2.2021   30 KB   3/1/2021   
  Blue_Shield_of_California_UM_MA_Authorization_Letter_10.06.2020   26 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Authorization_Letter_Spanish_10.06.2020   24 KB   1/14/2021   
  Blue_Shield_of_California_UM_MA_Carve_Out_Notice_10.06.2020   21 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Detailed_Explanation_of_Non-Coverage_10.06.2020   29 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Detailed_Explanation_of_Non-Coverage_Spanish_10.06.2020   29 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Detailed_Explanation_of_Non-Coverage_Spanish_10.06.2020   29 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Detailed_Notice_of_Discharge_10.26.2020   31 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Expedited_Criteria_Not_Met_10.06.2020   24 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Integrated_Denial_Notice_NDMC_10.6.2020   48 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Integrated_Denial_Notice_NDMC_Spanish_10.06.2020   47 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Multi-Language Insert_7.31.2020   502 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Non-Discrimination Notice_7.31.2020   109 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Non-Discrimination_Notice_SP_7.31.2020   114 KB   1/14/2021   
  Blue_Shield_of_California_UM_MA_Notice_of_Medicare_Non-Coverage_10.06.2020   36 KB   12/2/2020   
  Blue_Shield_of_California_UM_MA_Notice_of_Medicare_Non-Coverage_Spanish_10.06.2020   41 KB   12/2/2020   
  BlueShield_of_California_Claims_Medicare_Denial_of_Payment_IDN Templates 2020   55 KB   5/19/2020   
  BlueShield_of_California_Claims_Medicare_Denial_of_Payment_Spanish_IDN Templates 2020   57 KB   5/19/2020   
     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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