Application Documents
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DOCUMENTS |
NAMING CONVENTION |
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Exhibit 1: Categories of Personnel |
1 Personnel List |
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Exhibit 2: Adverse Determination (AD) Template Letters (3 types, listed below) |
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Initial AD Letter |
2 Initial AD |
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IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f) |
2 Initial STPTHRPY |
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IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056 |
2 Initial DRGFORM |
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IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006 |
2 Initial ABI |
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AD Appeal Acknowledgement Letter |
2 AD Ack Ltr |
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AD Appeal Determination Letter |
2 AD Appl Notice |
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IF there is separate letter for denial for step therapy; TIC Sec. 1369.0546(f) |
3 APL STPTHRPY |
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IF there is separate letter for denial for drug formulary; TIC Sec. 1369.056 |
3 APL DRGFORM |
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IF there is separate letter for denial for Acquired Brain Injury (ABI); TIC Sec. 1352.006 |
3 APL ABI |
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Additional content: Attestation |
ATTEST |
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Request for a Review by an Independent Review Organization (IRO) Instructions LHL009|0920 |
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Federal External Review Process Form |
FERP Form |
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Attestation |
ATTEST |
Additional Documents
If you want to include your own naming convention, add it at the end of the TDI naming convention.
Examples:
- AD LTR_NGF_YYYYMMDD NGF = Non-grandfathered or GF = Grandfathered
- AD LTR_N_20210716; N = only used to identify a “new” letter
- AD LTR_ Initial AD Partial_20210716 [Company naming convention]
- URA number_Response/Cover Letter_XXXXXXXX = 206_CVR LTR_20210825
- URA number_Approval Letter_TYPE_XXXXXXXX = 206_APPRVL LTR_U_20210825
- URA number_Deficiency Letter_TYPE_XXXXXXXX = 206_DEF LTR_U_20210825; U=update, R=renewal, O=original