Required Elements for Member Notification Letters

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)

Communications regarding decisions to approve 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
  • A description of the criteria or guidelines used
  • The clinical reasons for the decisions regarding medical necessity
  • Information on filing a grievance (or appeal)
  • Information on contacting the California Department of Insurance (DOI)