CT BHP – 40
08/06
CT BHP SAMPLE DENIAL LETTERS
ADMINISTRATIVE DENIAL LETTER…………………………………………PAGE 2 MEDICAL NECESSITY DENIAL LETTER…………………………………PAGE 3-4
Page 1
Administrative Appeal (denial)
CT BHP – 40
08/06
Date Name Address City, State Zip Administrative Denial Letter Member: Reference #: Provider: DOS:
Dear Name: for the above referenced This letter is in response to the request for authorization received on patient. The Connecticut Behavioral Health Partnership (CT BHP) has reviewed the information regarding the proposed treatment. The CT BHP has determined that the proposed services can not be authorized effective following reason(s): , for the
Member ID#: Level of Treatment: Provider Location:
DOB:
Registration or Prior Authorization procedures were not followed. Concurrent Review Procedures were not followed. The authorization has been exhausted. The treatment requested is not a covered service. This benefit package does not include out of network coverage. Delay in treatment. Other: YOU MAY NOT BILL THE MEMBER FOR THESE SERVICES. Payment may be denied or reduced if services are not authorized. There is an administrative appeal available which is the final level of appeal. An administrative appeal must be requested in writing within seven (7) calendar days of the receipt of this administrative denial. Please submit the written appeal to: The Connecticut Behavioral Health Partnership 500 Enterprise Drive, Suite 4D Rocky Hill, CT 06067 Attention: Denials & Appeals Department If you have any questions, please contact the Denials and Appeals Department at 1-877-55-CTBHP (877-552-8247). Sincerely, Denials & Appeals Department
Page 2
Administrative Appeal (denial)
CT BHP – 40
08/06
Date
Provider's Name Address City, State Zip Medical Necessity Denial Letter Member: Reference #: Provider: DOS:
Dear Provider's Name: for the above referenced patient. This letter is in response to the request authorization received on The Connecticut Behavioral Health Partnership (CTBHP) has reviewed the information regarding the proposed treatment. The CT BHP has determined that the proposed services can not be authorized effective following reason(s): , for the
Member ID#: Level of Treatment: Provider Location:
DOB:
The service(s) or good(s) requested is [are] not a covered service(s) or good(s); Explain: ______________________________________________________________________ The service or good your provider requested is not medically necessary because another service or good is medically appropriate for you. Explain:_______________________________________________________________________ _____________________________________________________________________________ [Identify alternative service or good] is being authorized as an equally safe and effective alternative which will meet your needs; Explain:______________________________________ _____________________________________________________________________________ [Identify alternative intensity or frequency or duration] is being authorized as an equally safe and effective alternative which will meet your needs; Explain:______________________________ _____________________________________________________________________________ The service(s) or good(s) requested is of an unproven, research, or experimental nature; Explain: _____________________________________________________________________ We have not received enough information from your provider to show that the service(s) or good(s) is [are] medically necessary for you. Your provider must give us information that shows
Page 3
Medical Necessity (denial)
CT BHP – 40
08/06
that the service(s) or good(s) is [are] medically necessary.; Explain: ____________________________________________________________________________ The service(s) or good(s) requested is [are] not medically necessary for you because: Explain: _____________________________________________________________________________ _____________________________________________________________________________ YOU MAY NOT BILL THE MEMBER FOR THESE SERVICES. Benefits may be denied or reduced if services are not authorized. There is a Medical Necessity Level I Appeal available. A Medical Necessity Level I Appeal must be requested verbally or in writing within seven (7) calendar days of the receipt of this medical necessity denial. Please submit the written appeal to: The Connecticut Behavioral Health Partnership 500 Enterprise Drive, Suite 4D Rocky Hill, CT 06067 Attention: Denials and Appeals Department If you have any questions, please contact the Denials and Appeals Department at 1-877-55-CTBHP (877-552-8247). Sincerely, Denials & Appeals Department
Page 4
Medical Necessity (denial)