How to Write an Effective Letter of Medical Necessity

 

Before you start writing:

1. Understand the law relating to insurance coverage

i)      Beneficiary must prove a covered loss by submitting the claim

(a)    The insurer will either pay or deny the claim

(b)   If the claim is denied, the insurer must prove loss is excluded from coverage

 

2) Understand the meaning of medical necessity

i)      Each insurer defines the term in a different manner

ii)     Get the insurance company you are approaching to fax or email their definitions of medical necessity.

(a)    It will be in the insurer’s benefits handbook in the summary plan description

 

3) Gear you letter to the audience

i)      Paint a picture of the beneficiary and create an understanding of the equipment

ii)     Use terms that can be understood by an ordinary person who has never worked in health care or heard of the equipment

 

4) State who you are in the opening sentence

 

5) Explain beneficiary’s condition

i)      Discuss the impact of the condition on the person’s life noting limitations without the mobility device

ii)     State the obvious: assume insurers haven’t experienced a person with the disabilities you are describing

 

6) Describe the equipment

i)      Explain how it will improve the beneficiary’s function

ii)     Explain why alternatives won’t improve beneficiary’s function

 

7) Explain how the equipment can replace other expenses and is cost-effective

i)      This is critical for equipment that is new and/or more expensive that other alternatives.

 

8) Address insurer’s definition of medical necessity

i)      Don’t go overboard, simply state that the policy requires that the equipment meet certain criteria in order to be considered medically necessary

ii)     Provide a one-sentence explanation of how each criterion is met

 

9) Make the beneficiary a real person facing a difficult adversity

 

10) Enclose a copy of the prescription

 

11) Download and print out file to accompany.