[HEALTH PLAN OR MEDICAL GROUP OR IPA LETTERHEAD]
HEALTHY FAMILIES PROGRAM PRE-SERVICE NOTICE OF ACTION
[Member Name] [or Member's representative] [Address] [City, CA, Zip]
Health Plan: Community Health Plan Medical Group/IPA: Member Name: Member ID: Requested Service: Requesting Provider: Primary Care Physician:
Dear [Member Name or Member's Representative]:
We have received a referral from the above provider. This notice is to inform you the service is being [insert one: modified, or delayed in delivery, or denied]. This decision was based on our review of your health condition in relation to and based on the terms and conditions of your Evidence of Coverage (EOC).
[INSERT SELECTED REASON FROM PRE-SERVICE TABLE OF DENIAL/MODIFICATION REASONS HERE]
[If this is a modification, and as applicable insert the following:] Instead of the service requested, we are recommending the following [insert treament or service]
The requesting provider has been advised of this denial and given the chance to discuss this decision with [insert name of Medical Group] physician reviewer.
How to Dispute This Determination If you believe that this determination is not correct, you have the right to appeal the decision by filing a grievance with your health plan. Your health plan requests that you submit your grievance within 180 days from the postmark date of this notice. You or someone you designate (your authorized representative) may submit your grievance verbally or in writing. You can call your health plan at the numbers listed below to learn how to name your authorized representative.
CHP HFP NOA Version 1.1.04