Service Denial Templates
- Participating Physician Groups (PPG)
Delegated participating physician groups (PPGs) and hospitals are required to notify a member in writing when a service is denied.
Service denial letters must specify:
- Letter date
- Member name
- Provider name
- Specific service
- Date of service for concurrent review, if applicable
- Reason for the denial - Service denials for members must include a denial message; refer to the Industry Collaboration Effort (ICE) website at www.iceforhealth.org/home.asp to download the Commercial Pre-Service Denial Reasons Matrix Guidelines and other templates
- Appeals process and information
- Health Net department name, address, and telephone number for appeals
- The Department of Managed Health Care (DMHC) Required Statement for language and telephone number
Health Net encourages PPGs and hospitals to use the standardized ICE-approved HMO service denial letter templates. Refer to the ICE website at www.iceforhealth.org/home.asp to view the following templates located under Approved ICE Documents:
- Commercial Service Denial Notice
- Commercial Delay Needed - Additional Information
- Notice of Non-Coverage - Termination of Services
- Acknowledgment of Receipt - Refusal to Sign
- Refusal to Transfer
- SNF Exhaustion of Benefits
- SNF Reinstatement Letter
- Carve-Out Situations
Letters to Members
Communications regarding decisions to approve prior authorization requests must state the specific health care service approved.
Member notification letters indicating a denial, delay or modification of service must include:
- A clear and concise explanation of the reasons for the decision specific to medical necessity, benefit coverage or eligibility
- A description of the criteria or guidelines used
- The clinical reasons for any decisions regarding medical necessity
- Information on filing a grievance (or appeal)
The Health Net provider website at provider.healthnet.com includes sample text from the Evidence of Coverage (EOC) for the Health Net commercial HMO line of business. When used in conjunction with the Schedule of Benefits, the EOC text can assist participating physician groups (PPGs) in determining coverage and medical necessity. PPG medical directors are encouraged to cite the language from the EOC text models, including the specific service provision and the definition of medical necessity, in the denial of service notification to the member. Denials based on any determinant of medical necessity require further substantiation by medical literature, utilization management (UM) criteria set (such as Milliman and Robertson or Interqual), or other reputable evidenced-based criteria.
Providers are encouraged to use the approved ICE Commercial Service Denial Notice template when sending service denial notices to their members; refer to the ICE website at www.iceforhealth.org/library.asp to view the template located under Approved ICE Documents.
Refer to the DMHC Required Statement for additional requirements.