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Required Elements for Provider Notification Letters

Provider Type

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

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Sacramento
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

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 www.iceforhealth.org/home.asp 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.

Last Updated: 10/30/2019