Family Care and Family Care Partnership: Notice of Adverse Benefit Determination Forms

For Family Care and Family Care Partnership, managed care organizations (MCOs) must give a written notice of adverse benefit determination to members if they:

• Stop a member’s services.
• Deny a member services.
• Reduce a member’s services.

The notice explains the member’s right to appeal the MCO’s decision. This page includes related forms and templates for this process.

Notice of adverse benefit determination 

• Family Care—Notice of Adverse Benefit Determination (Notice of Action), F-00232
• PACE—Notice of Denial of Medical Coverage—PACE, F-00950A
• Partnership—Notice of Adverse Benefit Determination for Partnership DSNP (Dual Eligible Special Needs Plan) (Coverage Decision Letter), F-00950

Other letter templates

• Decision Letter, Decision Reversed, F-00232D
• Decision Letter, Decision Upheld, F-00232E
• DSNP only—Family Care Partnership Appeal Decision Letter, F-02738 (Word)
• DSNP only—Family Care Partnership Letter about Your Right to Make a Fast Complaint, F-02739 (Word)
• MCO Letter: Notice of Change in Level of Care, F-10590
• Notification of Extension for a Decision of a Request, F-00232B
• Notification of Non-Covered Benefit Letter Template—Model, F-01283
• Template Language MCOs are Required to Use in Grievance and Appeal Materials, F-02619

Appeal forms

• Filing an Appeal
  • Appeal Request—MCOs, English, F-00237
  • Appeal Request—MCOs, Arabic, F-00237AR
  • Appeal Request—MCOs, Chinese (Simplified), F-00237CM
  • Appeal Request—MCOs, Hmong, F-00237H
  • Appeal Request—MCOs, Laotian, F-00237L
  • Appeal Request—MCOs, Serbo-Croatian, F-00237SE
  • Appeal Request—MCOs, Somali, F-00237SO
  • Appeal Request—MCOs, Spanish, F-00237S
• Request for a State Fair Hearing—MCO, F-00236
• Voluntary Withdrawal (of hearing request) (PDF)