PM FORM 5.1.1 Insert Logo Here If you have trouble reading this notice because the letters are too small or the words are hard to read, please call our office at XXX-XXX-XXXX and someone will help you. If this notice does not tell you what you asked for, what we decided and why, please call us at XXX-XXX-XXXX. This letter is available in other languages and formats if you need it. Si usted tiene problemas leyendo éste aviso debido a que las letras son muy pequeñas o las palabras son muy difíciles de leer, por favor llame a nuestra oficina al y alguna persona le ayudará. Si éste aviso no le proporciona la información que usted busca o la decisión que tomamos y el por qué, por favor llámenos al número Esta comunicación está disponible en otros idiomas y formatos si usted lo necesita. NOTICE OF ACTION TO: Date: FROM: You or your health care provider have asked that (RBHA pay for or RBHA Contractor) (describe services requested and the reason for the services in easily understood language). OUR DECISION (Insert action being taken here and date effective if terminating or reducing a current service). THE REASONS FOR OUR DECISION Facts About Your Condition or Situation that Support Our Decision (Insert the reason for the action, which must be complete and in commonly understood language. The explanation must be both member and fact specific, describing the and the reasons supporting the RBHA or Contractor decision. If the member’s condition reason for the denial is a lack of information, the missing information must be identified so the member has an opportunity to provide it.) Legal Basis for Our Decision
PM FORM 5.1.1 Insert Logo Here If you have trouble reading this notice because the letters are too small or the words are hard to read, please call our office at XXX-XXX-XXXX and someone will help you. If this notice does not tell you what you asked for, what we decided and why, please call us at XXX-XXX-XXXX. This letter is available in other languages and formats if you need it. Si usted tiene problemas leyendo éste aviso debido a que las letras son muy pequeñas o las palabras son muy difíciles de leer, por favor llame a nuestra oficina al y alguna persona le ayudará. Si éste aviso no le proporciona la información que usted busca o la decisión que tomamos y el por qué, por favor llámenos al número Esta comunicación está disponible en otros idiomas y formatos si usted lo necesita. NOTICE OF ACTION TO: Date: FROM: You or your health care provider have asked that (RBHA or RBHA Contractor) pay for (describe services requested and the reason for the services in easily understood language). OUR DECISION (Insert action being taken here and date effective if terminating or reducing a current service). THE REASONS FOR OUR DECISION Facts About Your Condition or Situation that Support Our Decision (Insert the reason for the action, which must be complete and in commonly understood language. The explanation must be both member and fact specific, describing the member’s condition and the reasons supporting the RBHA or Contractor decision. If the reason for the denial is a lack of information, the missing information must be identified so the member has an opportunity to provide it.) Legal Basis for Our Decision