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, including a reference to the specific regulation or authorization procedure(s) that supports the decision, as well as an explanation of the criteria or guidelines.
  • The requesting provider must be advised that:
    • “In accordance with Section 1367.03(a)(5)(H):
    • If this delay to obtain additional information and resulting delay will have a detrimental impact on the health of the member, you must contact the Plan.
    • If this delay will not have a detrimental impact on the health of the member, you must document this in the member record.”
    • If the decision was based on medical necessity, the notification must include a reference to the clinical criteria that has not been met.
    • If the denial is related to a member who has a terminal illness, a description of alternative treatment, drug, services or supplies covered by the Plan, if any.
• 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 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 Healthcare Industry Collaboration Effort (HICE) website at www.iceforhealth.org/home.asp to view the Denial File Fax Back template located under Approved HICE 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.