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Layers searched that had a match: 1 Federal law/regulation.
Layers with no match for this question: 2 State regulation (Virginia); 3 State Medicaid manual (DMAS); 4 MCO contract / provider manual; 4 MCO contract/manual; 5 Payer clinical criteria; 6-7 Accreditation / case law / guidance. A rule found in one layer can still be changed by another, especially the plan's own contract (layer 4) and the program's policies (layer 7), which are not loaded.
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F-004 Notice of denial must contain reasons and offer the criteria
The enrollee's written notice must state the determination, the reasons, and the right to free reasonable access to and copies of all relevant documents, including medical necessity criteria and any processes, strategies or evidentiary standards used to set coverage limits; plus appeal rights, expedited-appeal circumstances, and right to continued benefits. The MCO must also notify the requesting provider of a denial or partial approval.
438.404(b); 438.210(c) · rev eCFR as of 2026-09-28 · P
Caution The entitlement belongs to the enrollee; the provider typically makes the request with the member's written consent.