What should a Letter of Medical Necessity include?
• Name of child and names of parents (parents and child may have different names) • All ID Numbers, contacts, insurance information • Date of birth of child • Insurance plan name (there may be more than one plan) • Contact information for the plan • ALL relevant diagnoses (codes are helpful only if they are accurate!) • Item/service requested • Why item/service is medically necessary (refer to the plans’ definition) • What positive/negative impacts the item/service will result in (include financial) • Scope and duration of treatment • Supplemental documents (letters from other providers, research articles, product information, PAR, EPSDT Screen) • Funding streams NOT able to help or denied item
