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Denial Notice Template

Use this template for denial, closure, disenrollment, or other adverse-action notices that need to be understandable enough to challenge.

Notice header

• decision taken:
• effective date:
• claimant or member name:
• case or reference number:
• review owner:

Specific reason

• specific reason for the decision:
• rule, policy, or criterion relied on:
• what evidence was used:
• what is missing, disputed, or unresolved:

Decision record summary

• automated output, score, or flag involved:
• human reviewer or approver:
• whether the decision overrode or followed the automated output:

What the claimant can do next

• appeal deadline:
• how to appeal:
• how to submit additional evidence:
• how to request the full record:
• contact point for help:

Delivery check

• delivery method:
• language or accessibility accommodation:
• attachments included:

Quality check

Before sending, confirm:

• the reason is specific enough for a normal person to understand
• the notice reflects the actual basis of decision
• the appeal path and deadline are clear
• the responsible review owner is named

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