Template Notice Submission Cover Sheet

  • Template also available in Portable Document Format (PDF)
Date:

 Unique Identifier:
Plan Name:

 Vendor Name (if applicable):

1) Which HMO products will this notice be used for? (Check all that apply):
MMC         HARP         HIV SNP         Other: ______________________________________

2) Identify the template type (Check one):

    IAD no A/C     IAD with A/C     FAD no A/C     FAD with A/C
    Approval     Extension     Complaint     Complaint Appeal

3) Which decision types will this notice be used for? (Check all that apply):

    Utilization Review     Concurrent Review     Retrospective/ claims denials
    Administrative Denials     Out of Network
          (Not Materially Different)		     Substance Use Disorder Inpatient Treatment
    Partial Approvals     Out of Network
          (Training & Experience)		     Long Term Services & Supports
    Specific Service:_______________________________     Other: _________________________

Comments/Notes:

I affirm that the attached template notice will be utilized as indicated above and that all information is true and accurate to the best
of my knowledge. I understand that the New York State Department of Health is relying upon this attestation as part of its review and
approval process, and that should it be determined that this attestation is materially false or incomplete or incorrect or includes
incorrect, false or misleading, information, appropriate regulatory action will be taken.


__________________________________________________         ______________________________________________
                                                  Signature                                                                                                              Title

__________________________________________________         ______________________________________________
                                                      Email                                                                                                              Phone

Only the HMO may submit templates for review. Submit a completed cover sheet with each template to bigaplans@health.ny.gov

Rev 11/2021