For Family Care and Family Care Partnership, managed care organizations (MCOs) must give a written notice of adverse benefit determination to members if:
- They stop a member’s services.
- They deny a member services.
- They reduce a member’s services.
The notice explains the member’s right to appeal the MCO’s decision. This page includes related forms and templates for this process.
Notice of adverse benefit determination
- Family Care—Notice of Adverse Benefit Determination (Notice of Action), F-00232
- PACE—Notice of Denial of Medical Coverage—PACE, F-00950A
- Partnership—Notice of Adverse Benefit Determination for Partnership DSNP (Dual Eligible Special Needs Plan) (Coverage Decision Letter), F-00950
Other letter templates
- Decision Letter, Decision Reversed, F-00232D
- Decision Letter, Decision Upheld, F-00232E
- DSNP only—Family Care Partnership Appeal Decision Letter, F-02738 (Word)
- DSNP only—Family Care Partnership Letter about Your Right to Make a Fast Complaint, F-02739 (Word)
- MCO Letter: Notice of Change in Level of Care, F-10590
- Notification of Extension for a Decision of a Request, F-00232B
- Notification of Non-Covered Benefit Letter Template—Model, F-01283
- Template Language MCOs are Required to Use in Grievance and Appeal Materials, F-02619
- Filing an Appeal
- Appeal Request—MCOs, English, F-00237
- Appeal Request—MCOs, Arabic, F-00237AR
- Appeal Request—MCOs, Chinese (Mandarin), F-00237CM
- Appeal Request—MCOs, Hmong, F-00237H
- Appeal Request—MCOs, Laotian, F-00237L
- Appeal Request—MCOs, Serbo-Croatian, F-00237SE
- Appeal Request—MCOs, Somali, F-00237SO
- Appeal Request—MCOs, Spanish, F-00237S
- Request for a State Fair Hearing—MCO, F-00236
- Voluntary Withdrawal (of hearing request) (PDF)