Claims Denial Letter Requirements

Participating physician groups (PPGs) and capitated hospitals are required to notify the member and provider in writing within 45 business days when a claim is denied if the member has any financial responsibility for the charges. If denying the letter, PPGs are encouraged to use the Industry Collaboration Effort (ICE) Claim Denial Letter located under Approved ICE Documents on the ICE website at www.iceforhealth.org/library.asp. Claim denial letters must specify:

• Date of denial notice
• Member name
• Provider name
• Specific service
• Date of service
• Denied amount
• Member responsibility amount
• Reason for the denial - Claim denials for members must include a claim denial message. Use the ICE Commercial HMO Claim Denial Reasons Guide located under Approved Documents on the ICE website at www.iceforhealth.org/library.asp
• Provider and member appeals process and information, including plan name, address and telephone number for appeals. For disputes, include the Department of Managed Health Care (DMHC) Required Statement.

PPGs and hospitals may not send denial notices to capitated members if they are not financially liable for the services.

For emergency room (ER) claims denials, use the ICE Commercial Member ER Claim Denial Letter located under Approved ICE Documents on the ICE website at www.iceforhealth.org/home.asp.