Download NOTICE OF DENIAL

CONFIDENTIAL
[Insert Date]
[Member Name]
[Address]
[City, State Zip]
QUEST No:
Provider:
Service:
Case ID:
[HMSA No]
[Physician Name]
[Requested Service]
[Case ID#]
NOTICE OF DENIAL
We have denied coverage of the above-requested service.
Under the provisions of your QUEST member handbook, services and supplies that are
medically necessary when you are sick or hurt are covered. A medically necessary service or
supply follows standard medical practice and is required, appropriate and the most cost effective
for your illness.
According to the Food and Drug Administration (FDA) and the manufacturer's literature, this
drug is approved for (condition). Therefore, we are unable to approve this request.
Our Medical Director, [insert medical director's name] has reviewed this case.
If you are not satisfied with the explanation we are providing, you or your physician/provider
with your written consent may file an appeal in accordance with the procedures and timeframes
described in the Grievance and Appeal Rights & Procedures attachment.
If you or your physician/provider have any other questions or need further clarification regarding
this matter, please call QUEST Member Services at (808) 948-6486 on Oahu or 1 (800) 4400640 from the Neighbor Islands. Representatives are available Monday through Friday, 8 a.m. to
4 p.m., Hawaii Standard Time.
cc: [Physician Name]
cc: [Provider/Facility, as applicable]
Attachment
[initials]