RESOURCE COLLECTION
Notice of adverse benefit determination documents
BHS provider templates, additional notices, and decision guide for informing Medi-Cal members of an adverse benefit determination.
Documents
Template forms
Fillable template for notice of delay in processing authorization request. Also available in: Spanish, Chinese, 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, Russian, Tagalog, and Vietnamese.
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, 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, Russian, Tagalog, and Vietnamese.
Fillable template for notice about the termination, reduction, or suspension of services. Also available in: Spanish, Chinese, Russian, Tagalog, and Vietnamese.
Other documents
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: Chinese, Russian, Spanish, Tagalog, and Vietnamese.
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: Chinese, Russian, Spanish, Tagalog, and Vietnamese. English LARGE Print
Notice informing Medi-Cal members about how to request a second opinion regarding medical necessity criteria for SMHS or DMC services. Also available in: Chinese, Russian, Spanish, Tagalog, and Vietnamese.
Notice informing Medi-Cal members about an additional 120 days to request a State Fair Hearing after exhausting our county appeal process. Notice expires 9/24. Also available in: Chinese, Russian, Spanish, Tagalog, and Vietnamese.
Describes the criteria, timing, and likely users of each type of Notice of Adverse Benefit Determination.