Letter Templates
- TX - Denial of Coverage for Inpatient Hospitalization Provider Denial - English Last Modified: 9/30/2022
- TX - Detailed Explanation of Non Coverage - English Last Modified: 9/30/2022
- TX - Detailed Explanation of Non Coverage - Spanish Last Modified: 9/30/2022
- TX - Detailed Notice of Discharge - English Last Modified: 6/5/2023
- TX - Detailed Notice of Discharge - Spanish Last Modified: 6/5/2023
- TX - Extension Needed For Additional Information - English Last Modified: 9/30/2022
- TX - Extension Needed For Additional Information - Spanish Last Modified: 9/30/2022
- TX - Important Message From Medicare About Your Rights - English Last Modified: 6/5/2023
- TX Important Message From Medicare About Your Rights Spanish Last Modified: 6/5/2023
- TX - Informational Letter to Beneficiary And Or Provider Physician - English Last Modified: 12/19/2023
- TX - Informational Letter to Beneficiary And Or Provider Physician - Spanish Last Modified: 1/11/2024
- TX - Medicare Outpatient Observation Notice MOON - English Last Modified: 6/5/2023
- TX - Medicare Outpatient Observation Notice MOON - Spanish Last Modified: 6/5/2023
- TX - Notice of Authorization Services - English Last Modified: 9/30/2022
- TX - Notice of Authorization Services - Spanish Last Modified: 9/30/2022
- TX - Notice of Authorization Facility - English Last Modified: 9/30/2022
- TX - Notice of Authorization Facility - Spanish Last Modified: 9/30/2022
- TX - Notice of Denial of Medical Coverage - English Last Modified: 11/28/2023
- TX - Notice of Denial of Medical Coverage - Spanish Last Modified: 12/19/2023
- TX - Notice of Dismissal of PreService Request - English Last Modified: 6/9/2023
- TX - Notice of Dismissal of PreService Request - Spanish Last Modified: 6/9/2023
- TX - Notice of Medicare NonCoverage - English Last Modified: 9/30/2022
- TX - Notice of Medicare NonCoverage - Spanish Last Modified: 9/30/2022
- TX - Notice of Reinstatement of Coverage - English Last Modified: 9/30/2022
- TX - Notice of Reinstatement of Coverage - Spanish Last Modified: 9/30/2022
- TX - Optional Form to Document Alternate Delivery - English Last Modified: 9/30/2022
- TX - Second and Third Opinion Authorization - English Last Modified: 9/30/2022
- TX - Second and Third Opinion Authorization - Spanish Last Modified: 9/30/2022
- TX - Section 1557 Notice - Multi-Language - English Last Modified: 10/19/2023
- TX - Section 1557 Notice - Multi-Language - Spanish Last Modified: 10/19/2023
- TX - Services Requested Do Not Meet Expedited Criteria - English Last Modified: 9/30/2022
- TX - Services Requested Do Not Meet Expedited Criteria - Spanish Last Modified: 9/30/2022