Medical Necessity Letter
At Resolve, we know that dealing with certain aspects of healthcare to help you with your insurance claims and medical bills can be overwhelming. Learn how to get a medical necessity letter from your provider, the key terminology to know, and tips for submitting the letter to your insurance company from our team below.
What is a Medical Necessity Letter?
A Letter of Medical Necessity is a formal document written by your provider to explain why a specific test, service or treatment is medically required. It typically provides a detailed description of the patient’s relevant medical history, diagnosis and treatment.
The medical necessity letter explains why the course of patient care is:
- Necessary and likely to prevent, diagnose, cure or improve conditions that negatively affect the patient’s well-being
- More appropriate and cost-effective than the available alternatives
When and how do I obtain a Medical Necessity Letter?
Health insurance companies frequently deny claims for lack of medical necessity. In order to handle thousands of claims efficiently, they may use computer algorithms or blanket rules to make these determinations.
In reality, medical necessity is highly subjective and dependent on each patient’s unique condition and medical history. A qualified healthcare provider with knowledge of the patient’s condition and medical history will frequently disagree with the insurance company’s automated or uninformed claim denial.
If you have an insurance claim denied for lack of medical necessity, you should request that your doctor write a formal letter of medical necessity. You should receive a copy of the letter and ensure that it is delivered to the appropriate contact at your insurance company.
The Medical Necessity Letter Terminology to Know
- Medically Necessary: Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
- Insurance Appeal Letter: A standard document submitted to explain why a denied claim should be paid. If relevant, a medical necessity letter may be attached as part of your appeal submission.
Tips for Requesting and Sending a Medical Necessity Letter
Make sure that your doctor drafts a medical necessity letter that:
- Is published on formal letterhead, signed and dated
- Includes detailed identification for both patient and provider
- Details the diagnosis, treatment, and relevant medical history
- Explicitly affirms medical necessity and lack of a better or less costly alternative, citing supporting data and research if needed
Make sure that the medical necessity letter reaches the correct contact at your insurance company. Call to confirm receipt and expected timeline for your insurer to respond.
If you need help regarding your medical bills and insurance related issues, get in touch with our medical bill advocates at Resolve today.
