Writing a Letter of Medical Necessity

Writing a Letter of Medical Necessity

  1. Name of child, names of parents (parents and child may have different names)
  2. Date of birth of child
  3. Insurance plan name (there may be more than one plan)
  4. Relevant diagnoses (codes are helpful only if they are accurate!)
  5. Item/service requested
  6. Why item/service is medically necessary (refer to the plans’ definition)
  7. What positive/negative impacts the item/service will result on (include financial) scope and duration of treatment
  8. Supplemental documents (letters from other providers, research articles, product information, PAR)
  9. 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.

  1. 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

    1. pertinent benefits
    2. limitations and exclusions
    3. appeals process
    4. terms and their definitions
    5. distribute instructive materials to parents (empowerment)
    6. write perfect letters of medical necessity

Parent needs to

    1. become knowledgeable about the policy (a-d above)
    2. supply information to providers
    3. keep a paper trail of all communications
    4. confront conflicting information

Advocate’s role is to

  1. assist with the appeals process
  2. guide providers and parents to resources
  3. influence systems’ change

Health insurance plan’s staff member

    1. confuse the member as much as possible (i.e., change the rules often), and deny benefits to contain costs.

 

 

Sign the Petition to Improve Access to IDD Services

Sign the Petition to Improve Access to IDD Services

The Colorado Joint Budget Committee has voted to draft a bill to significantly strengthen supports for Coloradans with intellectual and developmental disabilities and their families. The legislation would fund 300 new waiver enrollments to reduce the waiting list, assist people with aging caregivers, and increase compensation for the critical workforce of Direct Support Professionals in Colorado. Learn more about the bill and see who’s already in support.  We need you – the Colorado IDD community – to tell the JBC and the General Assembly that you support this bill!
Take Action!
Sign YOUR Name to the Petition!

 

Opportunity to test Assistive Technology

Assistive Technology Partners is looking for people with hand weakness or limited hand coordination to participate in a 90-minute focus group to discuss the merits and limitations of a product for phone and tablet users.  The product is an attachment to phones and tablets that is designed to provide the user an alternate way to hold their device, as well as provide a means to position the device in a tilted orientation on a flat surface when it is not being held.

Possible diagnoses for participants would include multiple sclerosis, arthritis, stroke, spinal cord injury, cerebral palsy, muscular dystrophy, or functional impairment due to upper extremity injury.

During the focus group discussion, participants will asked to inspect and handle samples of the product mounted on phones and tablets.  In addition, some of the samples will still be in the package they come in when purchased.

Participants will be asked a structured set of questions on their thoughts and feelings about the product and its usefulness.  There will also be moderated discussions with the group about the value of the product, and other possible uses for it.

As compensation for your time and effort, participants will be given a $50 gift card at the completion of the focus group discussion. We will be asking people who are interested what days would work best for them before deciding on a date and time.

If you are interested or have any questions, please call or email.

Greg McGrew

Assistive Technology Partners

Bioengineering Department

University of Colorado Denver

Greg.mcgrew@ucdenver.edu

303-315-1289

Making Colorado a better place for children and youth with special health care needs