[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]. 

On [date], I received a letter denying [Beneficiary]'s request for coverage for [service] by [name of provider]. The reason for denial was listed as [reason listed for denial].

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

[Beneficiary] is under age 21 and is therefore entitled to these services through the EPSDT mandate. [Service] is medically necessary in order to ensure that [Beneficiary] can communicate effectively.

I am attaching a letter from [Beneficiary]’s [type of treatment provider], [name], who has determined that this intervention is evidence-based and medically necessary 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].

[Beneficiary] is not already receiving this service through the IDEA. I am attaching a copy of [his/her] most recent IEP. [Add details, if necessary, explaining why the service is different from those described in the IEP - e.g., the beneficiary is working towards different goals at school than those that the requested service would work towards; the beneficiary is only receiving the service during school hours and needs access to the same service outside school hours, etc.]

[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