CMS/ICE Approved Service Denial Templates
SCAN Quality Management Contact
Colleen Anderson, LVN
Senior Quality Management Coordinator
E-Mail: canderson@scanhealthplan.com
Ph: 562-989-5134
Fax: 562-290-0707
English
Detailed Explanation of Non-coverage
Download
Detailed Explanation of Non-Coverage Form Instructions
Download
Detailed Notice Of Discharge
Download
Extension Needed For Additional Information
Download
Important Message From Medicare About Your Rights
Download
Informational Letter To Beneficiary And/Or Provider/Physician
Download
Notice of Denial of Medical Coverage
Download
Notice of Denial of Medical Coverage Form Instructions
Download
Notice of Medicare Non-Coverage
Download
Notice of Medicare Non-Coverage Form Instructions
Download
Notice of Reinstatement of Coverage
Download
Optional Form to Document Alternate Delivery
Download
Services Requested Do Not Meet Expedited Criteria
Download
Note: Spanish and Chinese Service Denial Templates will be available soon.
