Medicare-Medicaid Plan Letter Templates

1. Carve-Out Information Letter 

     Last Updated: 11/21/17
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2. Carve-Out Information Letter (Spanish)

     Last Updated: 10/31/17
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3. Detailed Explanation of Non-Coverage  

     Last Updated: 10/31/17
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4. Detailed Explanation of Non-Coverage (Spanish) 

     Last Updated: 10/31/17
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5. Detailed Notice of Discharge 

     Last Updated: 10/31/17
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6. Detailed Notice of Discharge (Spanish) 

     Last Updated: 10/31/17
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7. Expedited Criteria Not Met 

     Last Updated: 10/31/17
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8. Expedited Criteria Not Met (Spanish) 

     Last Updated: 10/31/17
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9. Extension Needed for Additional Information 

     Last Updated: 10/31/17
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10. Extension Needed for Additional Information (Spanish)

     Last Updated: 10/31/17
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11.  Integrated Denial Notice

     Last Updated: 11/14/17
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12.  Integrated Denial Notice (Spanish) 

     Last Updated: 11/03/17
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13. Notice of Authorization of Services 

     Last Updated: 10/31/17
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14. Notice of Authorization of Services (Spanish)

     Last Updated: 10/31/17
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15. Notice of Medicare Non-Coverage  

     Last Updated: 10/31/17
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16. Notice of Medicare Non-Coverage (Spanish)

     Last Updated: 10/31/17
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17. Notice of Reinstatement of Coverage 

     Last Updated: 10/31/17

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18.  Notice of Reinstatement of Coverage (Spanish) 

     Last Updated: 10/31/17
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19.  Denial Reason Matrix

     Last Updated: 09/04/15
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