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Medical Necessity Appeal Letter Template
What Is a Medical Necessity Appeal Letter?
A Medical Necessity Appeal Letter is a document that individuals can use when they would like to appeal a decision by their insurance company. The purpose of the document is to prove that a medical service that the individual would like to receive (or has received) is a medical necessity and that the insurance company is required to cover it.
Alternate Name:
- Appeal Letter for Medical Necessity.
A medical necessity includes healthcare services that are reasonable and necessary to diagnose or treat the patient's medical condition. There are a lot of disputes about what can be considered a medical necessity and what is not, however, the decision in each case depends on the particular circumstances of the situation.
Generally, these types of appeal letters are prepared by patients. However, advocates and healthcare providers can also compile such kinds of letters on behalf of their patients. A Medical Necessity Appeal Letter template can be downloaded below.
How to Write a Medical Necessity Appeal Letter?
Writing a Medical Appeal Letter for a Medical Necessity can be rather intimidating, therefore, to make the process of compiling it easier you can follow a simple plan. Your appeal letter can contain the following parts:
- Information About the Addressee . The letter can start with information that would identify the person or entity that is supposed to receive it. It can include the name of the insurance company and its address. If you know a particular employee or department of the insurance company that is responsible for holding such a matter, you can state the name of the employee (or department) as well.
- Information About the Sender . Here, you are supposed to provide information that will identify the sender. If the letter is prepared by the patient, then they are supposed to indicate their name, address, insurance member ID (if applicable), and insurance policy details. If the letter is prepared by a healthcare provider (or advocate) of the patient, then they are supposed to designate their name and address in addition to the patient's details.
- Opening Greeting . Depending on whether you know who you are contacting or not, you can salute them by using their name or simple greetings such as "To Whom It May Concern," or "Dear Sir/Madam."
- Introduction . You can begin by referencing the denial letter that you have received from your insurance company, where they stated that the medical services you required are not a medical necessity.
- Medical Appeal Details . You can use this section of the document to determine that you disagree with the decision of the insurance company and provide evidence that will support your point of view. For this purpose, you can use doctors' opinions, hospital documents, clinical information, etc. All documents that you have referred to should be attached to your Medical Appeal Letter.
- Conclusion . At the end of the document, you can ask the insurance company to review your letter and consider changing their decision on your case. You can also offer to provide more information if they would like you to and include your contact details (telephone number and email).
Haven't found the letter you're looking for? Take a look at the related templates and samples below:
