[HEALTH PLAN OR PROVIDER ORGANIZATION LETTERHEAD] (Use font) COMMERCIAL Informational Letter to Member and/or Provider/Physician (Issue for carve-out situations when group is referring member and/or physician to another entity or source for authorization of services that the group does not have responsibility for authorizing.) [Date] [Name Member’s Name: of Member] [or DOB: Member’s representative] [Address] Member ID#: [City, Health Plan Name: State, ZIP] Attending Provider/Physician: Requested Service: Dear [Member Name]: This notice is to inform you that [insert under contract with provider organization name], [insert is not responsible for authorizing the above requested Health Plan name], service(s). This is not a denial of service. Please contact [insert at X-XXX-XXX-XXXX or TTY/TDD at Health Plan name Or, if known, insert other health care provider i.e., VSP at phone for further assistance regarding the requested service(s). number 1-XXX-XXX-XXXX] Sincerely, __________________________ Provider Organization Representative C: Member File Requesting Physician PCP Health Plan
[HEALTH PLAN OR PROVIDER ORGANIZATION LETTERHEAD] (Use font) COMMERCIAL Informational Letter to Member and/or Provider/Physician (Issue for carve-out situations when group is referring member and/or physician to another entity or source for authorization of services that the group does not have responsibility for authorizing.) [Date] [Name of Member] Member’s Name: [or Member’s representative] DOB: [Address] Member ID#: [City, State, ZIP] Health Plan Name: Attending Provider/Physician: Requested Service: Dear [Member Name]: This notice is to inform you that [insert provider organization name], under contract with [insert Health Plan name], is not responsible for authorizing the above requested service(s). This is not a denial of service. Please contact [insert Health Plan name at X-XXX-XXX-XXXX or TTY/TDD at Or, if known, insert other health care provider i.e., VSP at phone number 1-XXX-XXX-XXXX] for further assistance regarding the requested service(s). Sincerely, __________________________ Provider Organization Representative C: Member File Requesting Physician PCP Health Plan
UnitedHealthcare_ICE_Carve_Out_Situations_(COS)_Commercial_LAP_1557_100918.docx