Sample Letter Of Medical Necessity printable pdf download

Letter of Medical Necessity

DATE: ____________________________

Please check one:  HRA “Health Reimbursement Account

 FSA “Flexible Spending Account

Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for

reimbursement from your account when your doctor or other licensed health care provider certifies that

they are medically necessary. Your provider must indicate your (or your spouse’s or dependent’s)

specific diagnosis, the specific treatment needed, and how this treatment will alleviate your medical

condition.

This Letter of Medical Necessity will need to be submitted with every payment request for the below

Diagnosis and CPT Code(s). This Letter of Medical Necessity expires in one year.

Employee Name

Member ID Number

Patient Name

Employee Daytime Phone

Diagnosis

CPT Code

Please describe what the recommended treatment is, how treatment will alleviate the diagnosis or

symptoms, and the duration of the treatment required.

____________________________________________________________________________________________

Sincerely,

Provider Signature______________________________________________

Provider Name_________________________________________________

Provider License # and State____________________________________

Provider Telephone #___________________________________________

If you have questions you may contact The Health Plan Customer Solutions, toll-free, at 1-866-347-3640,

Monday through Friday, 8:30 am until 4:30 pm, Eastern Time.

You may fax this claim form to 1-304-347-3643 or 1-866-347-3643 (toll free).

Note: The Health Plan’s role is to ensure that the proper documentation is submitted for reimbursement under the Plan, and not

to determine whether the treatment prescribed by your doctor or other licensed health care provider is medically necessary.

THP will review this letter only for completeness.

PO Box 953

Charleston WV 25323

Sample Letter Of Medical Necessity