Insurance companies reimburse claims after they go through the approval processes. Sometimes a claim can be denied on the ground that it is not medically necessary. In such situations, the claimant needs to present medical evidence to prove the validity of their claim. The proof must be drafted by a practicing doctor and signed to be deemed valid. Its acceptability must be within the set standards for medical practice and treatment. Since the document is required for payment on claims made to insurance companies, it is necessary to understand what the medical necessity form means.
- 1 Letters of Medical Necessity
- 2 What is a letter of medical necessity?
- 3 Letter Of Medical Necessity Templates
- 4 Information required in a medical necessity form
- 5 How to get a letter of medical necessity?
- 6 Medical Necessity Forms
- 7 How do I write a letter of medical necessity?
- 8 Letters Of Diagnosis From Doctor
- 9 How do you prove medical necessity?
- 10 Letter of medical necessity example
- 11 Submitting a medical claim with a medical insurance company
Letters of Medical Necessity
What is a letter of medical necessity?
Practicing doctors use a letter of medical necessity template when preparing a letter to insurance companies to prove that a patient requires medical services. The doctor confirms to the insurance company that your medical expenses are genuine.
The letter of medical necessity does not apply to all types of diseases but to specific types of expenses. You can download the letter of medical necessity template online instead of designing it from scratch. The forms prove that your medical expenses are for a:
Letter Of Medical Necessity Templates
Information required in a medical necessity form
A medical necessity form can also be called a letter of diagnosis from doctor. It verifies the medical services you are receiving and the items you are purchasing. The services or items must be under the list of eligible expenses proofed by the right authorities. An eligible service or item means a necessary service, procedure, or treatment that will help a patient with benefits like:
- Prevention of the onset of a health condition
- Suppress the effects of a health condition
- Help a patient achieve or maintain the best body/organ functionality
Insurance companies would prefer a less invasive treatment that they can consider economical. However, the procedure or treatment might not be favored as the most economical method. In such situations, the doctors have no option but to apply invasive or more expensive procedures.
Because they are necessary for the survival of the patient, the doctor will be required to download the letter of medical necessity template and fill it. The patient will present it to their health insurer for their claims to be approved. What insurance companies would consider invasive procedures are:
- The more expensive drugs or brands that cannot be sold over the counter
- Costly surgical procedures
- Costly diagnosis procedures
The following information is required in a letter of diagnosis from doctor.
- Patient’s name
Details about the patient’s personal information includes their names, address, patient records number, insurance number, etc.
- Type of diagnosis or treatment required
The recommending doctor must be licensed. A doctor may recommend a patient to be attending the gym for a certain number of months as part of the therapy. Such a recommendation can be made if the patient is hypertensive. Because it is important for their quick recovery, the insurance company will honor the letter of diagnosis from doctor.
- Treatment duration
The doctor should state how long the treatment will take. If they don’t provide a duration, the insurance company will follow the letter of necessity guidelines which is one year from the date of the letter. If the duration exceeds 12 months, the patient has to submit a new letter of diagnosis from doctor.
- Other considerations
For the letter of medical necessity to be accepted, it must meet conditions like:
- It must be signed by the doctor who wrote it
- The doctor’s prescription must be attached to the medical necessity form
- The discharge papers must be attached
- The doctor’s letterhead might be required
- The medical necessity form must have a date
How to get a letter of medical necessity?
Many people have had a bad experience with their insurance companies after their claim was denied. The insurance company will have their reasons which a supported by law. No matter how many letters you write or call your insurer, they will deny you your claim. Your best defense is to provide them with a medical necessity form. The insurance company will honor the letter if it is signed by a licensed doctor.
There are two ways you can use to get the letter.
- Write the letter yourself
You can choose to write the letter yourself. In this case, what you need is to go online and download the letter of medical necessity template. The template is pre-designed by professionals and contains all the information that you need. Fill in the form and make sure you provide genuine information or the necessary information. After filling it out, take the form to your doctor and ask them to sign it for you.
The doctor will sign and stamp the document. After they sign, present it to the insurance company for reimbursement of your claim. You may also scan it together with the supporting documents and email it to the insurance company.
- Ask your doctor to write it for you
Your next option is to call your doctor and ask them to write a letter for you. The doctor will follow the same procedure. They will download the letter of medical necessity template, fill it and stamp it. They can email it to you, send it through the postal service, or you may collect it from their office.
Medical Necessity Forms
How do I write a letter of medical necessity?
Follow the following steps to write a letter of medical necessity.
Write the patient details and make sure you include the following information:
- Date:This is the date when the letter of medical necessity was written. The letter validity is calculated from the date it was written.
- Names: Write the patient names. The names must not conflict with how they appear in the insurance documents and your identification documents.
- Insured name: If the beneficiary is a minor, write the name of the insurance policyholder. In this case, it will be the parent of the child. If it is an employee, write the name of your employer.
- Policy number: This is the number of your insurance cover. It makes it easier for the insurance provider to retrieve your files.
- Group number: This can be Medicaid or Medicare number.
Names of physician
This is the health expert who is attending to the patient. The expert should indicate their area of expertise like gynecologist, dentist, endocrinologist, etc. They should indicate their relationship with the patient. This is in terms of the concerned illness.
The most recent evaluation
The doctor who is preparing the letter should write the date when they last examined the patient. In the letter, they must indicate what they diagnosed. The diagnoses should not be general but specific.
After the doctor recommends the prescription, they must provide the specific details of the prescription. If, for example, they prescribed calcium treatment, the prescription should include the daily quantities and the specific brand if necessary. They can write something like – Vitamin D 800 IU, Calcium supplements 1200 mg per day for 180 days.
Period of treatment
The doctor must state the period of treatment which must be specific. It can be three months, six months, one year, etc. If there is a need to exceed the period, the doctor will be required to prepare a new medical necessity form. If there is no time limit, many insurance companies will not honor the letter. Some companies may consider honoring it but they will cap it to twelve months, after which it lapses unless the doctor writes another letter.
Patient’s medical history
The medical history of the patient must be detailed. It can include all of the following:
- Write all the primary symptoms that you have recorded
- Include the treatments that you have provided previously.
- How the patient responded to the previously prescribed treatments
- Write any previous emergency room visits
- Include all previous hospitalizations
- History of medical procedures performed
- Failed previous medical treatments
- Treatments that were not tolerated
Write reasons for medical necessity
In this section, provide reasons why you believe the recommended treatment is medically necessary. You may include information like:
- The preventions it will provide
- How it will help with diagnosis
- How it will cure the condition
- How the patient’s life is endangered by the condition
- How the condition may cause suffering to the patient
- The pains, deformity, or malfunction that the condition might cause to the patient
The summarizing statement is the concluding statement. The doctor provides a concluding argument as to why the medical necessity is important for the patient. The statement should not leave loopholes for alternative treatment. The insurance company may look for loopholes as a basis for denying the claim.
The doctor must sign the document and include the following details:
- Their specialty
- License number
- Contact information – Telephone number, email, postal and physical address.
After the doctor signs the letter of medical necessity template, the following documents requires to be attached as supporting information.
- Discharge letters
- Laboratory tests forms and results
- Drug prescription forms
- Copies of patient medical literature
- Diagnosis literature
- Peer review literature
- Any other supporting documents
Letters Of Diagnosis From Doctor
How do you prove medical necessity?
When the time to file your claims come, there is often a possibility that some of the claims can be denied. Most health insurance plans will only pay for claims that they classify as medically necessary. To be certain that your claim will not be denied, you must provide concrete medical evidence that proves your claim is valid. If there are any loopholes, your claim can be denied even if you have the necessary documents.
According to the Centers for Medicine and Medicaid Services, a medical necessity case must meet the following conditions:
- It must prove to be effective and safe
- The situation must require the skills of therapists
- Have an appropriate duration and frequency. This is according to the laid-out diagnosis and treatment standards
- Be able to meet the medication needs of a patient
To document properly in a way that proves medical necessity, you require defensible documentation. You may want to refer to a letter of medical necessity example to help understand the documentation required.
Document every experience with the patient as much as possible. Every time a patient visits, the medical professional should document every encounter. There should be documented encounters.
- Follow up visits
- Therapy, etc.
Record in legible handwriting. Many times, doctors are not keen on handwriting. If the insurance employees cannot read what is written, they will ignore the document. Make sure you use clear handwriting.
Every document must be dated and signed. For every visit, make sure you include the date and signature after the patient’s visit.
Names: In every document, the patient’s name should be recorded in full and their identification number.
Tests: All the tests done and the measures taken should be what is standardized.
Clarity: The communication provided and the plan should have clarity.
There should be a record of the patient’s progress from the first time they visit the doctor. The documents should provide specific, measurable goals. There should be a document justifying information about the medical necessity of the patient.
Letter of medical necessity example
The letter of medical necessity example may differ from case to case. The design may not change, but the information will change with each case. In the first part, the doctor provides details of the patient’s name and the kind of medical attention they are receiving. The doctor provides details about the interventions done during the visits and their observations.
After some visits, the patient may not show signs of improvement. That is the time they recommend a higher level of care or medication. What must follow is the letter of medical necessity to help the patient file for claims successfully. Every necessary document must be provided.
Submitting a medical claim with a medical insurance company
It is easy to submit your documents. First, make sure the medical necessity form is well filled and signed by your doctor. Next, confirm with a letter of medical necessity example to make sure no document is left out. Finally, upload the form and all supporting documents and send them. Most insurance companies allow manual submission of documents. If you choose to physically submit the documents, attach every supporting document and submit them at the insurance company’s reception.