Required Elements for Provider Notification Letters

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
    (does not apply to HSP)
  • Hospitals

Communications regarding decisions to approve requests must state the specific health care service approved.

Provider notification letters indicating a denial, delay or modification of service must include:

  • A clear and concise explanation of the reasons for the decision
  • A description of the criteria or guidelines used
  • The clinical reasons for the decisions regarding medical necessity
  • Information on filing a grievance (or appeal)
  • The name and direct telephone number (or extension) of the physician or otherwise qualified and licensed health care professional (such as a PharmD) responsible for the decision

In the case of a denial, the referring provider must be given an opportunity to discuss the denial with the physician who made the denial decision. Refer to the Industry Collaboration Effort (ICE) website at to view the Denial File Fax Back template located under Approved ICE Documents. An expedient method for this purpose is to complete a Denial File Fax-Back Sample, including the name and telephone number of the physician who denied the service when faxing back the denial information.