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Looking for an approved ICE document/template? They can be found in the Approved ICE Documents folder - click here for a list of available documents for each ICE team: APPROVED ICE DOCUMENTS.

ICE documents can be altered for use by organizations/other regions as needed; however, the ICE logo/any ICE 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.


ICE is a voluntary 501(c)3 organization that includes participation by and advice from accrediting and regulatory agencies. The goal of ICE work products is to offer ICE participating organizations standardized tools and best practices toward optimizing efficiencies to implement health industry requirements. ICE heeds feedback from accrediting and regulatory agency partners regarding ICE work products; however, ICE does not obtain official regulatory approval for its work products. As such, ICE work products are not to be considered exempt from any approval process required by regulatory agencies.


APPROVED ICE DOCUMENTS

 Click to open category Appeals and Grievances Improvement Team  
 Click to open category Claims  
 Click to open category Claims Cal MediConnect Health Plan-Specific Member Denial Templates  
 Click to open category Claims CMS Health Plan-Specific Member Denial Letter Templates  
 Click to open category Claims Commercial Health Plan-Specific Member Denial Letter Templates  
 Click to open category Contracting & Compliance Team  
 Click to open category Contracting & Compliance Team IT Systems Integrity Workgroup  
 Click to open category Credentialing Shared Audit Policy Team - Main / California  
 Click to open category Credentialing Shared Audit Policy Team - Main / Mid-Atlantic  
 Click to open category Credentialing Shared Audit Policy Team - Main / Northwest  
 Click to open category Credentialing Shared Audit Policy Team - Main / Texas  
 Click to open category Cultural & Linguistic Services Team  
 Click to open category Cultural and Linguistics Provider Toolkit  
 Click to open category DMHC Access Regulations Team  
 Click to open category Encounters Standardization Team  
 Click to open category Provider Directory Updates Team  
 Click to open category QI / UM Team - Main  
 Click to open category Risk Adjustment Data Acquisition & Reporting (RADAR) Team  
 Click to open category Site Visit Team (falls under Credentialing Shared Audit Policy Team - Main / California)  
 Click to open category UM Required Reports Team (formerly QI and UM Required Reports Team)  
 Click to open category UM Templates & Tools (1) - Health Plan Posting Request Instructions  
 Click to open category UM Templates & Tools (Cal MediConnect) - Health Plan-Specific Templates  
 Click to open category UM Templates & Tools (Commercial UM LAP Templates for LAP Regulations Effective on and after 1/1/09)  
 Click to open category UM Templates & Tools (Commercial)  
 Click to open category UM Templates & Tools (Medi-Cal)  
 Click to open category UM Templates & Tools (Medi-Cal) - Health Plan-Specific Templates  
 Click to close category UM Templates & Tools (Medicare Advantage Templates for Marketing Guidelines)  
     Click to open category 00 - Template Availability
ICE posts whatever templates have been provided by participating health plans. Please contact the health plans directly for any templates not available on the ICE website.
     Click to open category 01 - Document Remediation
Please contact the health plans directly to determine if a specific document has been remediated to meet applicable accessibility standards and any policy that the health plans may have in place for remediation of documents.
     Click to close category Click to Download All Documents in Subfolder Aetna
       File   Upload   Review
  Title     Size   Date   Date
 1020 CA ONLY_PROVIDER No Longer In Network_Medicare_Member_NR_0009_10122   41 KB   10/27/2020   
 10-20 CA ONLY DENCenglishfinalword   41 KB   10/27/2020   
 1020 CA ONLY_Provider_Retraction_Medicare_Member_NR_0009_8530a   47 KB   10/27/2020   
 10-20 CA ONLY DND Y0001_3035_10918_NM_ENG CMS 10066   49 KB   10/27/2020   
 10-20 CA ONLY CMS-10003_NDMCP_Notice of Denial of Medical Coverage   64 KB   10/27/2020   
 10-20 CA ONLY CMS_10003_NDMCP_ Notice of Denial of Med Cov_SPANISH_   67 KB   10/27/2020   
 12-20 CA ONLY AETNA ME09_Notice of Medicare Non Coverage_Spanish   89 KB   1/7/2021   
 12-20 CA ONLY DENC AETNA ME11_ (Spanish version)   93 KB   1/7/2021   
 10-20 CA ONLY_AETNA ME04_Medicare_14_day_ext_for_standard   94 KB   10/27/2020   
 10-20 CA ONLY_AETNA ME12_Medicare expedited denial   95 KB   10/27/2020   
 10-20 CA ONLY_ AETNA ME07 Medicare Approval Letter   105 KB   10/27/2020   
 10-20 CA ONLY_AETNA ME03_Medicare_14_day_ext_for_expedited   107 KB   10/27/2020   
 10-20 CA ONLY AETNA ME09_Notice of Medicare Non-Coverage   116 KB   10/27/2020   
     Click to open category Anthem Blue Cross
     Click to open category Blue Shield of California
Please implement these health plan-specific letter templates on January 1, 2021
     Click to open category Brand New Day
     Click to open category Health Net
     Click to open category Inter Valley Health Plan
     Click to open category Sharp Health Plan
     Click to open category WellCare Health Plan
 Click to open category UM Templates & Tools (Medicare Advantage)  

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  Microsoft Word File
  Microsoft Excel File
  Microsoft PowerPoint File
  Microsoft Word XML File
  Microsoft Excel XML File
  Microsoft PowerPoint XML File
  Zipped File
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