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)