[Your Full Name]

[Your Address]

[Your Telephone Number]

[Date]

[Address][fn]

Re: [Name of Beneficiary], Member # [Member ID Number] Claim # [Claim Number]

To Whom It May Concern:

I am writing to request a Medi-Cal Fair Hearing for [Beneficiary]. [Beneficiary] is enrolled in [Medi-Cal Program or Managed Care Provider] in [County]. In order to ensure continuity of care, I am requesting aid paid pending the resolution of the hearing. 

On [date], I received a letter saying that [Beneficiary] will no longer receive coverage for [service] by [name of provider]. The reason for denial was listed as [reason listed for denial]. 

[Note whether the beneficiary changed Medi-Cal plans within the past 12 months. If so, note whether the beneficiary had received these services through his or her previous plan].

[Describe any previous efforts you may have made to appeal the decision internally]

[Service] is medically necessary in order to ensure that [Beneficiary] can communicate effectively. [Beneficiary] has already benefited from this service by [describe benefit] and is continuing to make progress toward [goal]. It is critical that [Beneficiary] continue to receive the service in order to continue making progress toward [goal], avoid loss of functional skills, and retain access to necessary communication supports.  

I am attaching a letter from [Beneficiary]’s [type of treatment provider], [name], who has determined that this intervention is evidence-based and medicallynecessary due to [describe specific needs of the beneficiary that will be addressed by the service]. The intervention will address these needs by [describe what is involved in the intervention or service].

[Add more detailed information if possible. If you are including other documents such as prior assessments, include a list of what you are sending here.]

If you need additional information, I can be reached at [telephone number and/or e-mail address]. 

Sincerely,

[Signature]

[Typed Name]

[fn] You can either address the letter to:

1. The county welfare department shown on the Notice of Action;
2. The California Department of Social Services, State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, California 94244-2430;
3. To the State Hearings Division at fax number (916) 651-5210 or (916) 651-2789; or
4.  Request a Hearing Online