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Grier Template Notice

  • MCC 1 (doc, 63kb) Denial of New Non-Covered Service before appeal
  • MCC 1a (doc, 62kb) Denial of New Non-Covered Service before appeal - amount not specified
  • MCC 1p (doc, 62kb) Denial of New Non-Covered Service before appeal - prescriber not specified
  • MCC 1pa (doc, 62kb) Denial of New Non-Covered Service before appeal - prescriber amount not identified
  • MCC 2 (doc, 43kb) Initial Denial of New Non-Covered Service upon reconsideration
  • MCC 2a (doc, 44kb) Initial Denial of New Non-Covered Svc upon reconsideration - amount not specified
  • MCC 2p (doc, 44kb) Initial Denial of New Non-Covered Svc upon reconsideration - prescriber not specified
  • MCC 2pa (doc, 44kb) Initial Denial of New Non-Covered Svc upon reconsideration -prescriber amount not specified
  • MCC 3 (doc, 62kb) Termination of Non-Covered Service
  • MCC 6 (doc, 61kb) Medical Necessity Denial of New Service before appeal
  • MCC 6a (doc, 61kb) Medical Necessity Denial of New Service before appeal - amount not specified
  • MCC 7 (doc, 45kb) Initial Medical Necessity Denial of New Service upon reconsideration
  • MCC 7a (doc, 46kb) Initial Medical Necessity Denial of New Svc upon reconsideratio-amount not specified
  • MCC 8 (doc, 57kb) Reduction of Service based on Medical Necessity
  • MCC 9 (doc, 61kb) Termination of Service based on Medical Necessity
  • MCC 10-11w (doc, 31kb) Waiver of Right to Stay 2-Bs.Days aFTER notice of Provider-Initiated Termination
  • MCC 10 (doc, 79kb) 2 business day advance notice of MCC-Initiated Hospital Discharge doc
  • MCC 11r (doc, 52kb) 2-Bs Day Notice of Provider-Initiated Reduction of BHO service for SPMI/SED, I/P psych, residential, or home health service, or service to treat a chronic condition across a continuum when next appropriate level of service not available
  • MCC 11rf (doc, 54kb) 2-Bs Day Notice of Provider-Initiated Reduction of BHO service for SPMI/SED, I/P psych, residential, or home health service, or service to treat a chronic condition across a continuum when next appropriate level of service not available
  • MCC 11t (doc, 68kb) 2-Bs Day Notice of Provider-Initiated Termination of BHO service for SPMI/SED, I/P psych, residential, or home health service, or service to treat a chronic condition across a continuum when next appropriate level of service not available
  • MCC 11tf (doc, 60kb) 2-Bs Day Notice of Provider-Initiated Termination of BHO service for SPMI/SED, I/P psych, residential, or home health service, or service to treat a chronic condition across a continuum when next appropriate level of service not available
  • MCC 12 (doc, 50kb) General Delay
  • MCC 12.net (doc, 45kb) Network Shortage Delay
  • MCC 12.N-PCPterm (doc, 48kb) Non-PCP Termination Delay
  • MCC 12.PCP (doc, 52kb) PCP Change Delay
  • MCC 13 (doc, 42kb) Prior authorization of Ongoing Service