Writing a Letter of Medical Necessity
- Name of child, names of parents (parents and child may have different names)
- Date of birth of child
- Insurance plan name (there may be more than one plan)
- Relevant diagnoses (codes are helpful only if they are accurate!)
- Item/service requested
- Why item/service is medically necessary (refer to the plans’ definition)
- What positive/negative impacts the item/service will result on (include financial) scope and duration of treatment
- Supplemental documents (letters from other providers, research articles, product information, PAR)
- Include funding streams NOT able to help (denial letters help)
Terms to use; medically necessary, clinically based, promoting independence, preventing secondary disability, cost-effective, safety.
Terms to avoid; custodial, rehabilitate, developmental delay/disability, speech delay (without a diagnosis such as aphasia), Caregiver convenience.
- Ask if your Letter of Medical Necessity answers the following:
- Is there a licensed provider stating in writing the item/service is medically necessary?
- Is this item/service not for care giver convenience?
- Is this item/service costs effective and if so have you explained how?
- Is this item/service considered standard medical practice?
- Have you explained how long and how often the item/service will be used.
- Is this item/service right for the need of individual?
The Responsibilities of Each Role
Care provider needs to know the process if the parent is not yet skilled
- pertinent benefits
- limitations and exclusions
- appeals process
- terms and their definitions
- distribute instructive materials to parents (empowerment)
- write perfect letters of medical necessity
Parent needs to
- become knowledgeable about the policy (a-d above)
- supply information to providers
- keep a paper trail of all communications
- confront conflicting information
Advocate’s role is to
- assist with the appeals process
- guide providers and parents to resources
- influence systems’ change
Health insurance plan’s staff member
- confuse the member as much as possible (i.e., change the rules often), and deny benefits to contain costs.