(Insert Name/Address/Email Address and Telephone Number of the Notice of Action Administrative Denial of Request for Medicaid Services «Date_of_Letter» VIA TRACKABLE MAIL: {Fill from Tracking Number} «Name» Beneficiary: «Name» or GUARDIAN of «Name» MID: «MID» «Street» County of Origin: «County_of_Origin» «City», «State» «Zip» Service Authorization Request #: «SAR» Dear «Name» or GUARDIAN of «Name»: We are writing to explain a decision about services requested for you. (Insert Name of is responsible for approving Medicaid authorizations for people receiving mental health, intellectual/developmental disabilities, and/or substance use services in (Insert Name of Medicaid County). We are sending you this Notice of Action because you or Beneficiary’s your provider asked to approve the following Medicaid services: (Insert Name of LME-MCO) Date Request was received Service/Amount Authorization Period Decision Decision by (Insert Requested Requested Date Name of LME-MCO Denied (Insert Date) (Insert Service (Insert dates requested) (Insert and units) Decision Date) (Insert Name of LME-MCO) could not approve this service as requested. This Notice of Action explains the reason for our decision and tells you how to appeal if you disagree. (Insert Name of LME-MCO) followed criteria found in <<Clinical Coverage Policy/Waiver>> and was not able to review the request for because there was a «Insert Service_Requested» problem with the request. The problem with the request was: Reason for Administrative Denial - cite the specific reason(s) the request cannot be reviewed or does not meet the minimum requirements specified in the applicable clinical coverage policy» The full clinical rationale used in making this decision will be provided in writing upon request. To request the clinical rationale, please contact the Appeals Department at (Insert Name of at (Insert LME-MCO Telephone Number). Authority of (Insert Name of LME-MCO) (Insert Name of LME-MCO) has the authority to make decisions about Medicaid services because we have a Contract with the North Carolina Medicaid agency pursuant to 42 C.F.R. Part 438. We can only approve services that are medically necessary. We base our decision to approve
(Insert Name/Address/Email Address and Telephone Number of the Notice of Action Administrative Denial of Request for Medicaid Services «Date_of_Letter» VIA TRACKABLE MAIL: {Fill from Tracking Number} «Name» or GUARDIAN of «Name» «Street» «City», «State» «Zip» Beneficiary: «Name» MID: «MID» County of Origin: «County_of_Origin» Service Authorization Request #: «SAR» Dear «Name» or GUARDIAN of «Name»: We are writing to explain a decision about services requested for you. (Insert Name of is responsible for approving Medicaid authorizations for people receiving mental health, intellectual/developmental disabilities, and/or substance use services in (Insert Name of Beneficiary’s Medicaid County). We are sending you this Notice of Action because you or your provider asked (Insert Name of LME-MCO) to approve the following Medicaid services: Date Request was received by (Insert Name of LME-MCO Service/Amount Requested Authorization Period Requested Decision Date Decision (Insert Date) (Insert Service and units) (Insert dates requested) (Insert Decision Date) Denied (Insert Name of LME-MCO) could not approve this service as requested. This Notice of Action explains the reason for our decision and tells you how to appeal if you disagree. (Insert Name of LME-MCO) followed criteria found in <<Clinical Coverage Policy/Waiver>> and was not able to review the request for «Insert Service_Requested» because there was a problem with the request. The problem with the request was: Reason for Administrative Denial - cite the specific reason(s) the request cannot be reviewed or does not meet the minimum requirements specified in the applicable clinical coverage policy» The full clinical rationale used in making this decision will be provided in writing upon request. To request the clinical rationale, please contact the Appeals Department at (Insert Name of at (Insert LME-MCO Telephone Number). Authority of (Insert Name of LME-MCO) (Insert Name of LME-MCO) has the authority to make decisions about Medicaid services because we have a Contract with the North Carolina Medicaid agency pursuant to 42 C.F.R. Part 438. We can only approve services that are medically necessary. We base our decision to approve
Admin-denial-12-7-15.docx