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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
Participating health plans that have confirmed the templates have been reviewed to determine regulatory compliance are able to use a self-service web-based tool to upload their health plan-specific templates to this site. Please contact the plans directly for any templates not available on the HICE website. To receive broadcast messages when letter templates are added/updated by participating 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_CA_UM_Medi-Cal_INSTRUCTIONS_FOR_USING_NOTICES_OF_ACTION_rev_02.2022   142 KB   2/16/2023   
  01_DMHC IMR Website Link   15 KB   2/16/2023   
  01A_DMHC IMR Form_Standard Print   3710 KB   12/20/2023   
Implementation Date for Notice/Description: 1/31/2024
  01B_DMHC IMR Form_Large Print   3593 KB   1/4/2024   
Implementation Date for Notice/Description: 1/31/2024
  02A_Anthem Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_Standard Print   14132 KB   2/21/2024   
Implementation Date for Notice/Description: 3/21/2024
  02B_Anthem Blue_Cross_UM_Medi-Cal_Nondiscrimination_LEP_Large Print   11700 KB   2/23/2024   
  03_Anthem_Blue_Cross_UM_Medi-Cal_Your_Rights_Attachments   674 KB   2/16/2023   
  04A_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State Fair Hearing_Standard Print   3802 KB   12/20/2023   
Implementation Date for Notice/Description: 1/31/2024
  04B_Anthem_Blue_Cross_UM_Medi-Cal_NOA_State Fair Hearing_Large Print   9015 KB   12/20/2023   
Implementation Date for Notice/Description: 01/31/2024
  05_Anthem_Blue_Cross_UM_Medi-Cal_NOA_DENIAL_Templates   3803 KB   2/16/2023   
  06_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Modify_Templates   6953 KB   2/16/2023   
  07_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Carve-out_Templates   412 KB   2/16/2023   
  08_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Spec_Term_Letter_Templates   3185 KB   2/16/2023   
  09_Anthem_Blue_Cross_UM_Medi-Cal_NOA_Delay_Templates   253 KB   2/16/2023   
  Anthem Blue Cross_UM_CA EAE_Int Cov Dec_TEMPLATES(1)   89536 KB   3/28/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem Blue Cross_UM_CA EAE_NDN_MLI_TEMPLATES(1)   10064 KB   3/28/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem Blue Cross_UM_CA EAE_State Fair Hearing Attachments   412 KB   6/14/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem Blue Cross_UM_CA EAE_Your Rights_Notices   8188 KB   4/7/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem_Blue_Cross_CLAIMS_CA EAE_Your Rights_Notices   11241 KB   6/14/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem_Blue_Cross_CLAIMS_CA_EAE_Inter Cov Dec_TEMPLATES   91180 KB   6/14/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem_Blue_Cross_CLAIMS_CA_EAE_MLI_TEMPLATES   11108 KB   6/14/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem_Blue_Cross_CLAIMS_CA_EAE_State Fair Hearing Attachments   6617 KB   6/14/2023   
Implementation Date for Notice/Description: 1/1/2023
  Anthem_Blue_Cross_Claims_Medicare_CMS IDN_Notice of Denial of Payment_2023.03_ENGLISH_v2   43 KB   7/21/2023   
  Anthem_Blue_Cross_Claims_Medicare_CMS IDN_Notice of Denial of Payment_2023.03_SPANISH_v2   43 KB   7/21/2023   
  Anthem_Blue_Cross_UM_Commercial_Authorization_Notification_rev_5.16.17   163 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Commercial_CA_Only_Delegate_Specialist_Term_10.2020   35 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Commercial_Pended_Notification_Template_rev_5.16.17   114 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Commercial_Service_Denial_Notice_(CSDN)_rev_08.15.2023 (Clean)   121 KB   8/16/2023   
Implementation Date for Notice/Description: 8/16/2023
  Anthem_Blue_Cross_UM_Commerical_Carve_Out_Letter_Template_rev_5.16.17   164 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_Carve_Out_Template_02.2012   43 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_Clinical_MLI_Insert_Standard_01.01.23   371 KB   2/16/2023   
Implementation Date for Notice/Description: 1/1/23
  Anthem_Blue_Cross_UM_Medicare_HMO_Approval_Ltr_11.16.17   51 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_HMO_DENC_9.16   75 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_HMO_Dismissal_of_Prior_Auth_Request_Notice   37 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_HMO_Extension_Standard_Expedited_Review_Ltr_11.16.17   50 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_NOMNC_05.23.19   41 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_Notice_of_Reinstatement_of_Coverage_02.27.12   41 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_Specialist_Term_Template_For Delegate Use_10.2020   62 KB   2/16/2023   
  Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_CHINESE_v2   47 KB   7/21/2023   
  Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_ENGLISH_v2   41 KB   7/21/2023   
  Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_03_23_SPANISH_v2   39 KB   7/21/2023   
  Anthem_Blue_Cross_UM_Medicare_UM_CMS_IDN_Model_Notice_2023_05_23_VIETNAMESE   42 KB   4/8/2024   
     Click to open category Cigna
     Click to open category Clever Care Health Plan
     Click to open category Health Net
     Click to open category Sharp 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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