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Notice Templates

  • MCC 1  Denial of New Non-Covered Service before appeal
  • MCC 2  Initial Denial of New Non-Covered Service upon reconsideration
  • MCC 3  Termination of Non-Covered Service
  • MCC 6  Medical Necessity Denial of New Service before appeal
  • MCC 7  Initial Medical Necessity Denial of New Service upon reconsideration
  • MCC 8  Reduction of Service based on Medical Necessity
  • MCC 9  Termination of Service based on Medical Necessity
  • MCC 10-11w  Waiver of Right to Stay 2-Bs.Days after notice of Provider-Initiated Termination
  • MCC 10  2 business day advance notice of MCC-Initiated Hospital Discharge doc
  • MCC 11pr  Post Reduction 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 11pt  Post Termination 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 11r  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  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  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  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  General Delay
  • MCC 12.net  Network Shortage Delay
  • MCC 12.N-PCPterm  Non-PCP Termination Delay
  • MCC 12.PCP  PCP Change Delay