RE: Notice of Action IRIS Program – Dear , IRIS Program policy requires that participants be notified when there is an adverse action defined as a denial, limitation, reduction, or termination of previously authorized services (meaning services/goods on a or when a participant’s plan), requests for additional services, participant is determined to be ineligible for the program. This notification is known as a Notice of Action (NOA). This notice is to inform you that your request for has been denied. Enclosed you will find a detailed copy of your Notice of Action, including why this decision was made, as well as your options to appeal this decision. You have forty-five (45) days from the date of this letter to request a State Fair Hearing. If you have any questions, please contact your IRIS Consultant. Sincerely, Amy Chartier, IRIS Section Chief Bureau of Adult Programs and Policies IRIS Management Section DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services F-01204 (02/2018) NOTICE OF ACTION IRIS PROGRAM – NOA Reference Number Participant’s Name (Last, First) Decision Date Effective Date The purpose of this notice is to inform you about the IRIS decision to your Program’s The program has reached this decision based on the following factor(s): Informal support is available to provide sufficient support for your outcome. Specialized transportation definition does not cover reimbursement to yourself. The request does not meet an IRIS Medicaid Waiver Service definition.
RE: Notice of Action – IRIS Program Dear , IRIS Program policy requires that participants be notified when there is an adverse action defined as a denial, limitation, reduction, or termination of previously authorized services (meaning services/goods on a participant’s plan), requests for additional services, or when a participant is determined to be ineligible for the program. This notification is known as a Notice of Action (NOA). This notice is to inform you that your request for has been denied. Enclosed you will find a detailed copy of your Notice of Action, including why this decision was made, as well as your options to appeal this decision. You have forty-five (45) days from the date of this letter to request a State Fair Hearing. If you have any questions, please contact your IRIS Consultant. Sincerely, Amy Chartier, IRIS Section Chief Bureau of Adult Programs and Policies IRIS Management Section DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01204 (02/2018) STATE OF WISCONSIN NOTICE OF ACTION – IRIS PROGRAM Participant’s Name (Last, First) NOA Reference Number Decision Date Effective Date The purpose of this notice is to inform you about the IRIS Program’s decision to your The program has reached this decision based on the following factor(s): Informal support is available to provide sufficient support for your outcome. Specialized transportation definition does not cover reimbursement to yourself. The request does not meet an IRIS Medicaid Waiver Service definition.
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