(SAMPLE DTR from Minnesota)

 

HEALTH PLAN LETTERHEAD

 

 

This is not a bill

 

 

DATE

 

 

To:   Name of Member                                                      Member PMI#:

        Street Address of Member                                          Date of Birth:

        City, State, Zip                                                          Provider Name:

                                                                                        First Date of Service:

 

 

THIS IS A NOTICE OF:    DENIAL OF PAYMENT                     (MCO insert one)

                                     DENIAL OF SERVICE

                                     TERMINATION OF SERVICE

                                     REDUCTION OF SERVICE

 

FOR :  (Insert Type of Service)

 

THIS PAYMENT/ SERVICE (MCO choose one) IS DENIED/TERMINATED/REDUCED (MCO choose one) BECAUSE:  (Insert Reason Description)          

 

 

LAW/RULE/POLICY:

 

For Questions or to ask if there are exceptions to this decision, please call __________­­­­­­­­­­­­­­­­__________.  You may also check your Certificate of Coverage.

 

If you do not agree with this decision you may file an appeal.  Please see the back of this document for appeal information.

 

ADA Language:

This information is available in other forms to people with disabilities by calling 000-000-0000 (voice), or 1-800-000-0000 (toll free), or 000-000-0000 (TDD), or 711, or through the Minnesota Relay at 1-877-627-3848 (speech to speech relay service).

 

Notice will also be sent to Provider and State Ombudsman