Approval Notice
MODEL MLTC/MMC Approval Notice (Revised 11/17)
FOR SERVICE AUTHORIZATION, RECONSIDERATION, AND APPEAL DECISIONS
- Notice also available in Portable Document Format (PDF)
Template begins below this line
MCO/MLTC OR DUAL LETTERHEAD FOR PLAN AND UR AGENT/BENEFIT MANAGER]
[Plan Name] [UR AGENT/Benefit Manager Name]
[Address]
[Phone]
APPROVAL NOTICE
[Date]
Enrollee]
[Address]
[City, State Zip]
Enrollee ID: [ID number or CIN]
Coverage type: [coverage type]
Service: [describe requested or claimed service including: amount/duration/date of service]
Provider: [requesting provider]
Plan Reference Number: [Plan reference number]
Dear [Enrollee]:
You are getting this notice because your health plan has [now] approved your [Service].
{Insert for Requested Services}[On [Date of Request] you asked [Plan Name] for the service listed above.]
{Insert for Appeal Resolutions} [On [Date of IAD], [Plan Name] [denied] [partially approved] [reduced] [suspended] [stopped] this [service]. You appealed that decision on [Date of Appeal Request]. [Insert summary of appeal.] On [Date of Appeal Resolution], the appeal was decided in your favor.
{Insert for Approval on Reconsideration}[On [Date of IAD], Plan Name] [denied] [partially approved] [reduced] [suspended] [stopped] this [service]. Your provider asked us to reconsider our decision on [Date of Reconsideration Request]. We decided to approve this service on [Date of Approval].]
[UR Agent Name] on behalf of] [Plan Name] has decided this service is [a covered benefit] [medically necessary] [approved to be provided by an out–of–network provider] [other determination].
[{insert as for approval upon concurrent review, request for increase, or LTSS}
[{insert as applicable}[Before this decision, from [STARTDATE] to [ENDDATE], this service was approved for:
[HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc., and PREVIOUS TOTAL AMOUNT.]]
{insert as applicable}[You or your provider requested approval for:
[HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc.]]
On [EFFDATE], the plan approved:
[HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc.]
This means from [NEWSTARTDATE] to [NEWENDDATE], your health care service is approved for:
[HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc. AND NEW TOTAL AMOUNT]
{Insert as applicable} [We will review your care again [IN TIME FRAME/ ON DATE.]]]
[{insert for fully overturned decision upon appeal concurrent review, request for increase or LTSS}
{Insert as applicable}[From [STARTDATE] to [ENDDATE], the plan approved:
[HOURS/DAYS, VISITS, LEVEL, QTY, etc., and PREVIOUS TOTAL AMOUNT]]
{Insert as applicable}[ON [Date] you or your provider requested approval for: [HOURS/DAYS, VISITS, LEVEL, QTY, etc.]]
On [DATEIAD] the plan approved: [HOURS/DAYS, VISITS, LEVEL, QTY, etc., and IAD TOTAL AMOUNT].
On [EFFDATE], the plan approved: [HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc.]
This means from [NEWSTARTDATE] to [NEWENDDATE], your health care service is approved for:
[HOURS/DAYS, HOURS/WEEK, VISITS, LEVEL, QTY, etc. AND NEW TOTAL AMOUNT]
{Insert as applicable}[We will review your care again [IN TIME FRAME/ ON DATE].]]]
[[Provider Name] is a [participating provider.] [an out of network provider. You are not responsible for any extra payments, but you will still have to pay your regular co–pay or co–insurance if you have any.] {or} [This [service] will be provided by [a participating provider.] [an out of network provider. You are not responsible for any extra payments, but you will still have to pay your regular co–pay or co–insurance if you have any.]]
{Insert as applicable}[insert plan disclosure statement regarding authorization subject to continued coverage, possible benefit limitations that may be reached prior to the enrollee receiving the authorized service, and/or payment is subject to the terms of the provider contract and plan policies and procedures.]
If you would like to speak to [Insert Plan Name] about this decision, please call [1–800–MCO PLAN]. {Insert as applicable}[To speak to {Insert UR Agent Name}, please call [1–800–UR AGENT].
You can file a complaint about your managed care at any time with the New York State Department of Health by calling [{for MMC}[1–800–206–8125] {or for MLTC} [1–866–712–7197
Sincerely,
[MCO/UR AGENT/BENEFIT MANAGER Representative]
cc: Requesting Provider
{Insert as applicable}[At your request, a copy of this notice has been sent to:
[Enrollee Representative(s)]
NOTICE OF NON–DISCRIMINATION
[PLAN NAME] complies with Federal civil rights laws. [PLAN NAME] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
[PLAN NAME] provides the following:
- Free aids and services to people with disabilities to help you communicate with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Free language services to people whose first language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, call [PLAN NAME] at <toll free number>. For TTY/TDD services, call <TTY>.
If you believe that [PLAN NAME] has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with [PLAN NAME] by:
Mail: [ADDRESS], [CITY], [STATE] [ZIP CODE],
Phone: [PHONE NUMBER] (for TTY/TDD services, call <TTY>)
Fax: [FAX NUMBER]
In person: [ADDRESS], [CITY], [STATE] [ZIP CODE]
Email: [EMAIL ADDRESS]
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by:
Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail: U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F, HHH Building
Washington, DC 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Phone: 1–800–368–1019 (TTY/TDD 800–537–7697)
| ATTENTION: Language assistance services, free of charge, are available to you. Call <toll free number> <TTY/TDD>. | English |
| ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al <toll free number> <TTY/TDD>. | Spanish |
| 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 <toll free number> <TTY/TDD>. | Chinese |
| ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم toll free numberوالبكم الصم هاتف رقم<TTY/TDD>. | Arabic |
| 주의 : 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다<toll free number> <TTY/TDD> 번으로 전화해 주십시오. | Korean |
| ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <toll free number> (телетайп: TTY/TDD). | Russian |
| ATTENZIONE: In caso la lingua parlata sia l´italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero <toll free number> <TTY/TDD>. | Italian |
| ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le <toll free number> <TTY/TDD>. | French |
| ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele <toll free number> <TTY/TDD>. | French Creole |
| אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון .toll free number/TTY/TDD< רופט .אפצאל | Yiddish |
| UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer <toll free number> <TTY/TDD> | Polish |
| PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa <toll free number/TTY/TDD>. | Tagalog |
| লক্ষ ্য করুনঃ যদি আপদন বাাংলা , কথা বলতে পাতেন , োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে । ফ ান করুন ১ -<toll free number> <TTY/TDD> | Bengali |
| KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në <toll free number> <TTY/TDD>. | Albanian |
| ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε <toll free number> <TTY/TDD>. | Greek |
| ںیرک لاک ۔ ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںیہ ےتلوب ودرا پآ رگا :رادربخ <toll free number> <TTY>. | Urdu |
