Eleven Point Checklist Template For Writing An Effective Letter Of Medical Necessity

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Eleven Point Checklist
for Writing an Effective Letter of Medical Necessity
Rifton Equipment
PO Box 260
Rifton, NY 12471
Before you start writing
1.
Understand the law relating to insurance coverage
800-571-8198
a.  Beneficiary must prove a covered loss by submitting a claim
Fax: 800-865-4674
i.  The insurer will either pay or deny the claim
ii. If the claim is denied, the insurer must prove loss is excluded from coverage
2. Understand the meaning of medical necessity
a.  Each insurer defines the term in a different manner
b.  Get the insurance company you are approaching to fax or email their definitions
of medical necessity. Study it carefully and be sure to include it in your letter.
i. It will be in the insurer’s benefits booklet
  a . You will find the definition of medical necessity in the “summary plan
description”
3. Gear your letter to your audience
a.  Paint a picture of the beneficiary and create an understanding of the equipment
b. Use terms that can be understood by an ordinary person who has never worked
in health care or heard of the equipment
Starting your letter
4. State who you are in the opening sentence
5. Explain beneficiary’s condition
a. Discuss the impact of the condition on the person’s life noting limitations
without the adaptive equipment
b.  State the obvious: assume insurers haven’t experienced a person with the
disabilities you are describing
6. Describe the equipment
a.  Explain how it will improve the beneficiary’s function
b. Explain why alternatives won’t improve beneficiary’s function
7. Explain how the equipment can replace other expenses and is cost-effective
a. This is critical for equipment that is new and/or more expensive than other
accepted alternatives
8. Address insurer’s definition of medical necessity
a. Don’t go overboard; simply state that the policy requires that the equipment
meet certain criteria in order to be considered medically necessary
b. 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 pictures of the product
(or send the enclosed picture, if you
received this information by mail)
a. Enclose pictures with your letter

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