BỘ SƯU TẬP TÀI NGUYÊN
Thông báo về các tài liệu xác định lợi ích bất lợi
Mẫu nhà cung cấp BHS, thông báo bổ sung và hướng dẫn quyết định để thông báo cho các thành viên Medi-Cal về quyết định quyền lợi bất lợi.
Tài liệu
Mẫu biểu mẫu
Fillable template for notice of delay in processing authorization request. Also available in: Spanish, Chinese (Traditional), Russian, Tagalog, and Vietnamese.
Fillable template for notice that medical necessity criteria is not met for SMHS and a referral provided to non-SMHS or other services. Also available in: Spanish, Chinese, Russian, Tagalog, and Vietnamese.
Fillable template for notice of service denial. Also available in: Spanish, Chinese, Russian, Tagalog, and Vietnamese.
Fillable template for notice of denying Medi-Cal member's request to dispute a financial liability. Also available in: Spanish, Chinese (Traditional), Vietnamese, Russian, and Tagalog.
Fillable template for notice about delay in resolution of a Medi-Cal member's grievance or appeal. Also available in: Spanish, Chinese, Russian, Tagalog, and Vietnamese.
Fillable template for notice about change in approved services. Also available in: Spanish, Chinese (Traditional), Russian, Tagalog, and Vietnamese.
Fillable template for notice about the denial of a provider's request for payment for a service already provided to the Medi-Cal member. Also available in: Spanish, Chinese (Traditional), Vietnamese, Russian, and Tagalog.
Fillable template for notice about the termination, reduction, or suspension of services. Also available in: Spanish, Chinese, Vietnamese, Russian, and Tagalog.
Fillable template for notice about a delay in timely access to services. Also available in: Spanish, Chinese, Vietnamese, Russian, and Tagalog.
Các tài liệu khác
Notice informing Medi-Cal members of their rights to file an appeal. Medi-Cal members have 60 days from the date of the "Notice of Adverse Benefit Determination" to file an appeal. Also available in: Spanish, Chinese (Traditional), Vietnamese, Russian, and Tagalog.
The taglines inform members, potential enrollees, and the public of the availability of no-cost language assistance services, including assistance in non-English languages and the provision of free auxiliary aids and services for people with disabilities. If you need help in your language call 1-888-246-3333 (TTY: 711).
This notice informs members, potential enrollees, and the public about nondiscrimination, protected characteristics, and accessibility requirements. Also available in: Spanish, Chinese, Vietnamese, Russian, and Tagalog.
Describes the criteria, timing, and likely users of each type of Notice of Adverse Benefit Determination.