Notice of Adverse Benefit Determination (NOABDs) aren’t the most exciting part of health plan operations. Navigating the complex layers of federal and state requirements is often tedious, time-consuming, and labor-intensive. And in many organizations, people treat NOABDs more like a series of compliance boxes to check—something they “have to do.”
Health plans are already looking for ways to improve the NOABD process. They want to work faster and reduce backlogs. Many are also exploring how automation and AI can help.
But the bigger improvement opportunity goes beyond efficiency. Because NOABDs are one of the most visible and impactful communications a health plan sends.
Yet recipients rarely view these letters in a positive way. This is not only because they bring bad news. They may deny, reduce, or limit benefits. It is also because of how they deliver the message.
NOABDs are often long, dense, and formulaic. They often fail to highlight “need to know” information. This includes what happened, why it happened, and what the member can do next.
The good news is that many of the same issues make NOABDs less ideal for communication. These same issues also hurt operational efficiency. So, when done well, NOABD modernization can turn a long, technical denial notice into a clear notice.
It can feel fair and human.
It can improve member understanding and streamline operations.
NOABDs were built for compliance, not comprehension
A Notice of Adverse Benefit Determination (NOABD) is required for communication under both federal and state Medicaid regulations. These letters must include specific elements, such as:
- The reason for the denial or adverse action
- The member’s right to appeal
- Information about continuation of benefits
- Instructions for accessing further support
Over time, these requirements have expanded. Regulatory updates, audit expectations, and legal risk mitigation have layered additional language and disclosures into NOABDs year after year.
In response, health plans have used a compliance-first approach. They focus on including every required element. They also ensure each element is defensible under audit.
But that focus often comes at the expense of clarity. Instead of prioritizing what members need to understand, NOABDs often focus on what regulators need to see. The result is a communication that technically meets requirements, but fails to effectively serve the person receiving it.
In practice, this has led to three systemic challenges.
Problem 1: Letters are too long
How we got here
NOABDs have grown longer and more complex over time. This is due to expanding rules and requirements. It also reflects added legal and risk-mitigation language.
Many NOABDs now include multiple enclosures and inserts. They also use more redundant or overly detailed explanations. The result is a document that can feel overwhelming, even for experienced professionals. It can feel even more overwhelming for members in a stressful healthcare situation.
For members, this creates real consequences:
- Key deadlines are missed because they’re buried in dense paragraphs
- Important explanations are difficult to find or understand
- Next steps are unclear
- Trust in the communication, and the organization behind it, breaks down
How to improve
Modernizing NOABDs starts with making them easier to read and understand:
- Using plain language instead of overly technical or legal terminology
- Structuring content with clear headings, white space, and visual hierarchy
- Focusing on the core questions every member has: What happened? Why did it happen? What can I do next?
Simple additions, like clear section labels (“What this means for you” or “What to do next”), can greatly improve understanding. Plain-language explanations should come first. Add full regulatory citations and longer text as supporting content or attachments, when required.
Problem 2: Templates have become too rigid
How we got here
To manage complexity and ensure compliance, most health plans rely heavily on standardized templates to generate NOABDs. Templates improve efficiency and reduce the risk of missing required elements. They also create consistent formatting, style, and language across communications.
Auditors also favor them because they like familiar formats that help them quickly check compliance. They don’t need to read every letter.
But there’s a downside. Over time, templating can move toward a copy-and-paste exercise. Analysts may reuse standard language for medical necessity explanations or policy citations, often inserting large blocks of text with minimal customization. This leads to two major issues:
- Conflicting with CMS expectations that each NOABD be specific to the individual member and case
- Creating communications that feel generic, impersonal, and disconnected from the member’s situation
How to improve
The goal isn’t to eliminate templates, but rather to use them in smarter ways. Modern NOABD templates should:
- Use structured frameworks with dynamic personalization fields
- Provide clear guidance on where case-specific details are required
- Integrate directly with utilization management (UM) and claims systems to pull in accurate, relevant data
- Include governance processes to manage version control and state-specific variations
This approach keeps the efficiency and compliance benefits of templates. It also tailors each message to make it relevant and easy to understand.
Problem 3: Instructions are unclear
The final challenge is not just how much information you include, or how personal it is. How you present it is what it’s about. To be blunt, many NOABDs feature critical instructions that are difficult to follow:
- Deadlines buried in long paragraphs
- Confusion between plan appeals and state fair hearings
- Continuation-of-benefits rights that aren’t clearly explained
- Expedited appeal processes that are difficult to understand
When instructions aren’t clear, the impact can be serious. Members may miss appeal deadlines. You can lose services during the review process. Grievances may increase. Regulatory scrutiny can grow.
Keys to clearer instructions
Clear communication can directly improve outcomes, and health plans can start by making some high-impact changes to NOABDs:
- Providing step-by-step appeal instructions
- Using visual hierarchy to highlight key actions and deadlines
- Including timelines, bolded dates, and action-oriented callouts
- Clearly separating different appeal pathways
These changes still meet regulatory requirements. They also make it much easier for members to understand and act on the information.
NOABD modernization is a governance strategy, not a formatting exercise
NOABDs are among the most sensitive and high-risk communications in Medicaid. They sit at the intersection of compliance, operations, and member experience. And while people often treat them as just documentation, they shape how members see fairness, transparency, and trust.
When done right, NOABD modernization can be a strategic capability. It can reduce operational friction, improve member understanding, and build trust at a critical moment. But achieving these outcomes demands much more than formatting updates. Health plans need to take a holistic, governance-driven approach that aligns regulatory requirements with human-centered communication design.
How Toppan Merrill can help
Toppan Merrill helps health plans transform high-risk, compliance-driven communications into clear, effective, and member-centered experiences. Our solutions combine deep expertise in Medicaid regulations with advanced document automation and omnichannel delivery capabilities. We help organizations streamline workflows, improve accuracy and compliance, and design clear communications. Members can understand them easily and take action.
From template governance and system integration to content design and delivery, Toppan Merrill helps health plans modernize member communications. It balances compliance, efficiency, and the member experience.
Learn more about Toppan Merrill Health Plans Member Communications.
