Letter Templates

• CA - Coverage Decision Letter - English Last Modified: 1/11/2024
• CA - Coverage Decision Letter - Spanish Last Modified: 1/11/2024
• CA - Coverage Decision Letter - Chinese Last Modified: 1/11/2024
• CA - Coverage Decision Letter - Korean Last Modified: 1/11/2024
• CA - Denial of Coverage for Inpatient Hospitalization Provider Denial Last Modified: 11/16/2021
• CA - Detailed Explanation of Non Coverage - English Last Modified: 12/28/2021
• CA - Detailed Explanation of Non Coverage - Spanish Last Modified: 12/28/2021
• CA - Detailed Explanation of Non Coverage - Chinese Last Modified: 6/5/2023
• CA - Detailed Notice of Discharge - English Last Modified: 6/5/2023
• CA - Detailed Notice of Discharge - Spanish Last Modified: 6/5/2023
• CA - Detailed Notice of Discharge - Chinese Last Modified: 6/5/2023
• CA - Detailed Notice of Discharge - Korean Last Modified: 6/5/2023
• CA - Extension Needed For Additional Information - English Last Modified: 1/13/2022
• CA - Extension Needed For Additional Information - Spanish Last Modified: 1/13/2022
• CA - Extension Needed For Additional Information - Chinese Last Modified: 1/13/2022
• CA - Important Message From Medicare - English Last Modified: 6/5/2023
• CA - Important Message From Medicare- Spanish Last Modified: 6/5/2023
• CA - Important Message From Medicare - Chinese Last Modified: 6/5/2023
• CA - Important Message From Medicare - Korean Last Modified: 6/5/2023
• CA - Informational Letter to Beneficiary and/or Provider/Physician - English Last Modified: 12/19/2023
• CA - Informational Letter To Beneficiary And Or Provider Physician - Spanish Last Modified: 1/11/2024
• CA - Informational Letter To Beneficiary And Or Provider Physician - Chinese Last Modified: 1/11/2024
• CA - Informational Letter To Beneficiary And Or Provider Physician - Korean Last Modified: 1/11/2024
• CA - Medicare Outpatient Observation Notice (MOON) - English Last Modified: 6/5/2023
• CA - Medicare Outpatient Observation Notice (MOON) - Spanish Last Modified: 6/5/2023
• CA - Medicare Outpatient Observation Notice (MOON) - Chinese Last Modified: 6/5/2023
• CA - Medicare Outpatient Observation Notice (MOON) - Korean Last Modified: 6/5/2023
• CA - Notice of Authorization Facility - English Last Modified: 12/28/2021
• CA - Notice of Authorization Facility - Spanish Last Modified: 12/28/2021
• CA - Notice of Authorization Facility - Chinese Last Modified: 12/28/2021
• CA - Notice of Authorization - Services - English Last Modified: 7/26/2022
• CA - Notice of Authorization - Services - Spanish Last Modified: 7/26/2022
• CA - Notice of Authorization - Services - Chinese Last Modified: 7/26/2022
• CA - Notice of Authorization - Services - Korean Last Modified: 7/26/2022
• CA - Notice of Denial of Medical Coverage - English Last Modified: 11/28/2023
• CA - Notice of Denial of Medical Coverage - Spanish Last Modified: 12/19/2023
• CA - Notice of Denial of Medical Coverage in Chinese Last Modified: 12/19/2023
• CA - Notice of Denial of Medical Coverage - Korean Last Modified: 12/19/2023
• CA - Notice of Dismissal of Pre-Service Request - English Last Modified: 6/9/2023
• CA - Notice of Dismissal of Pre-Service Request - Spanish Last Modified: 6/9/2023
• CA - Notice of Dismissal of Pre-Service Request - Chinese Last Modified: 6/9/2023
• CA - Notice of Dismissal of Pre-Service Request - Korean Last Modified: 6/9/2023
• CA - Notice of Medicare Non-Coverage - English Last Modified: 1/13/2022
• CA - Notice of Medicare Non-Coverage - Spanish Last Modified: 7/7/2022
• CA - Notice of Medicare Non Coverage - Chinese Last Modified: 1/13/2022
• CA - Notice of Medicare Non-Coverage - Korean Last Modified: 1/13/2022
• CA - Notice of Reinstatement of Coverage - English Last Modified: 12/28/2021
• CA - Notice of Reinstatement of Coverage - Spanish Last Modified: 12/28/2021
• CA - Notice of Reinstatement of Coverage - Chinese Last Modified: 1/13/2022
• CA - Optional Form to Document Alternate Delivery - English Last Modified: 12/28/2021
• CA - Second and Third Opinion Authorization - English Last Modified: 9/13/2022
• CA - Second and Third Opinion Authorization - Spanish Last Modified: 9/13/2022
• CA - Second and Third Opinion Authorization - Chinese Last Modified: 9/13/2022
• CA - Section 1557 Notice - Multi-Language - English Last Modified: 10/19/2023
• CA - Section 1557 Notice - Multi-Language - Spanish Last Modified: 10/19/2023
• CA - Section 1557 Notice - Multi-Language - Chinese Last Modified: 10/19/2023
• CA - Section 1557 Notice - Multi-Language - Korean Last Modified: 10/19/2023
• CA - Services Requested Do Not Meet Expedited Criteria - English Last Modified: 1/13/2022
• CA - Services Requested Do Not Meet Expedited Criteria - Spanish Last Modified: 1/13/2022
• CA - Services Requested Do Not Meet Expedited Criteria - Chinese Last Modified: 1/13/2022