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Family Care and Family Care Partnership: Notice of Adverse Benefit Determination Forms

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.
  • Deny a member services.
  • 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 

Other letter templates

Appeal forms

Last revised April 24, 2023