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Service Denial Templates

Language
Denial of Coverage for Inpatient Hospitalization (Provider Denial)
Detailed Explanation of Non-Coverage - English
Detailed Explanation of Non-Coverage - Spanish
Detailed Explanation of Non-Coverage - Chinese
Detailed Notice of Discharge - English
Detailed Notice of Discharge - Spanish
Detailed Notice of Discharge - Chinese
Extension Needed For Additional Information - English
Extension Needed For Additional Information - Spanish
Extension Needed For Additional Information - Chinese
Important Message From Medicare About Your Rights - English
Important Message From Medicare About Your Rights - Spanish
Important Message From Medicare About Your Rights - Chinese
Informational Letter To Beneficiary And/or Provider/Physician - English
Informational Letter To Beneficiary And/or Provider/Physician - Spanish
Informational Letter To Beneficiary And/or Provider/Physician - Chinese
Notice of Denial of Medical Coverage - English
Notice of Denial of Medical Coverage - Spanish
Notice of Denial of Medical Coverage - Chinese
Notice of Denial of Medical Coverage Transportation Vendors – English
Notice of Medicare Non-Coverage - English
Notice of Medicare Non-Coverage - Spanish
Notice of Medicare Non-Coverage - Chinese
Notice of Reinstatement of Coverage - English
Notice of Reinstatement of Coverage - Spanish
Notice of Reinstatement of Coverage - Chinese
Optional Form to Document Alternate Delivery - English
Services Requested Do Not Meet Expedited Criteria - English
Services Requested Do Not Meet Expedited Criteria - Spanish
Services Requested Do Not Meet Expedited Criteria - Chinese