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Letters of Medical Necessity

A letter of medical necessity (LMN) or letter of justification (LOJ) is a detailed prescription that a therapist or physician writes to be submitted to the insurance provider. The letter should be client specific and not just a list of the medical benefits of standing. eSpecial Needs offers Sample Letters of Medical Necessity which can be emailed to you, your therapist, or your physician. The purpose of the Sample Letter of Medical Necessity is to act as a starting point or template that should be completed by a therapist or physician working with your child’s or client’s diagnosis and specific needs. We hope that by providing these templates, we can provide a good starting point and more assistance to our customers in funding equipment through insurance, waiver or other funding programs. All information submitted is confidential.

The sample letters take about 3-5 days to generate after we have received your client’s information below. The letter will then be emailed to you in a Word format for modification with specific client information. Once the information is received, our office may call you to clarify additional information.

First Name:
Last Name:
Address:
City:
State:
Country:
Zip:
Phone:
Fax:
Email:
  Yes, I would like to join the mailing list.

Client's Name:

Gender:
Date of Birth:
Height:
Weight:
Prognosis:
Diagnosis:

Product Needed:

Any additional accessories or items?

Physician Info

Physician's Name:
Physician's Phone:

Previous Equipment:
(if applicable or if product is being replaced)

Make:
Model:
Condition:
Issue with Equipment:

With as much detail as possible, explain how this service or benefit will prevent an illness or disability. How do you feel this equipment/service/evaluation will help your child?

Image Verification:
(CAPTCHA is case sensitive)
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The effectiveness of a funding advocacy/ medical necessity letter can be greatly enhanced if a clinician understands the legal issues involved, pertinent components of a medical necessity letter, and writes the letter in a manner that lays the groundwork for the appeals process if needed.

Before writing the letter, confirm the following:
     • the child is covered by the insurance
     • the diagnosis is a covered diagnosis (e.g., developmental delay may not be covered)
     • the item requested is not an exclusion of the policy (e.g. physical therapy)


Helpful Articles

O'Brien S, Parker S, Greenberg J, Zuckerman B.
Putting children first: the pediatrician as advocate.
Contemporary Pediatrics. 1997;:103-118.
This article defines the process of advocating for health care funding and gives specific examples of effective and ineffective letters for Medicaid funding. It also gives information on how to become active in community advocacy and the legislative process.
http://archpedi.ama-assn.org/cgi/reprint/159/9/842.pdf

Writing letters of medical necessity
http://findarticles.com/p/articles/mi_go2827/is_3_33/ai_n7617679/

Wheelchair and Seating Evaluations
http://www.wheelchairnet.org/WCN_Prodserv/Consumers/evaluation.html#anchor2244483


How to Write an Insurance Appeal Letter

http://www.ehow.com/how_4670354_write-insurance-appeal-letter.html

EVERY REASONABLE EFFORT HAS BEEN MADE TO VERIFY THE ACCURACY OF THE INFORMATION. HOWEVER, THE SAMPLE LETTERS OF MEDICAL NECESSITY ARE NOT INTENDED TO PROVIDE SPECIFIC GUIDANCE ON HOW TO APPLY FOR FUNDING FOR ANY PRODUCT OR SERVICE. HEALTH CARE PROVIDERS SHOULD MAKE THE ULTIMATE DETERMINATION AS TO WHEN TO USE A SPECIFIC PRODUCT BASED ON CLINICAL APPROPRIATENESS FOR A PARTICULAR PATIENT AND APPLICATIONS TO ANY FUNDING SOURCE MUST ACCURATELY REFLECT THE FACTS UNIQUE TO INDIVIDUAL APPLICATIONS. THIRD PARTY PAYMENT IS AFFECTED BY NUMEROUS FACTORS AND ESPECIALNEEDS CANNOT GUARANTEE THE SUCCESS IN OBTAINING INSURANCE OR THIRD PARTY PAYMENTS OF ANY KIND.

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