Required Elements for Member Notification Letters

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)