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

Authorization delay - English

Fillable template for notice of delay in processing authorization request. Also available in: Spanish, Chinese (Traditional), Russian, Tagalog, and Vietnamese.

Delivery system - English

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.

Denial - English

Fillable template for notice of service denial. Also available in: Spanish, Chinese, Russian, Tagalog, and Vietnamese.

Financial liability - English

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.

Grievance - appeal resolution - English

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.

Modification - English

Fillable template for notice about change in approved services. Also available in: Spanish, Chinese (Traditional), Russian, Tagalog, and Vietnamese.

Payment denial - English

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.

Termination - English

Fillable template for notice about the termination, reduction, or suspension of services. Also available in: Spanish, Chinese, Vietnamese, Russian, and Tagalog.

Timely access - English

Fillable template for notice about a delay in timely access to services. Also available in: Spanish, Chinese, Vietnamese, Russian, and Tagalog.

Other documents

NOABD Your Rights - English

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.

Notice of Availability (Language Assistance Taglines)

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).

Nondiscrimination Notice - English

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.

Provider Decision Grid

Describes the criteria, timing, and likely users of each type of Notice of Adverse Benefit Determination.

Partner agencies

Department of Public Health

Behavioral Health