How do you help ensure that your letter is published and is as compelling to readers as possible?
Medical necessity is a legal, not a medical, definition. This section includes an explanation of medical necessity, directions for writing a letter, and a template for a letter that can be adapted for use appealing medication, equipment, or other service denials. Click here for a brochure explaining how to write a letter of medical necessity.
Click here for a template letter of medical necessity that you can cut and paste onto letterhead. Click here for a template to attach to managed care pharmacy prior authorization forms requesting non-formulary medications.
Denied services, or services requiring prior authorization, must be medically necessary. Under Pennsylvania Medical Assistance, a service is medically necessary if it meets any one of the three standards below: The service or benefit will, or is reasonably expected to, prevent the onset of an illness condition, or disability The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition or disability.
The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.
How do I use this definition for a prior authorization? You can either write a letter using the above language, or use our template to request the equipment, medication, or service.
If you are using a managed care medication prior authorization form, include or attach documentation with the above language to support your judgment of the necessity of the non-formulary medication. It is critical to include all relevant medical information; many denials are issued for inadequate information.
What can patients or practitioners do if they disagree with an insurance decision to deny services? Patients can either file a grievance with the plan, which is an internal review, or request a fair hearing directly from the Department of Human Services.
Filing a grievance with the plan does not preclude later asking for a fair hearing. If the initial appeal is denied, a patient can file a second level grievance and subsequently request an independent external review. A grievance is a request to reconsider a decision concerning medical necessity or appropriateness of a health service.
If a service is approved only in part e. If a patient is receiving a service — whether it is a medication, an inpatient stay, or skilled nursing at home or in a facility — which is then denied in whole or in part, if the denial is appealed within ten days the managed care plan must continue to cover the service until the dispute is resolved.
Request a fair hearing from the Department of Human Services. An Administrative Law Judge will preside over the hearing, and DHS or the managed care plan will have to justify its denial of services.
Practitioners can usually participate by telephone. What if a denied service is urgent for the patient?
File an expedited grievance or request for fair hearing, which must be resolved within 72 hours. The option to request an expedited appeal is only available to patients in a managed care plan. What is my role as a physician in this procedure?
If you have prescribed something for your patient which you believe is indicated, and the insurance issues a denial, the best way to help your patient is to write an excellent letter of medical necessity and to participate in the fair hearing.
Grievances are part of the legal contract. This is a good time to have the patient call the Pennsylvania Health Law Project, Its legal advocates will be able to advise the patient and to provide representation if appropriate. So these rules apply to commercial insurance?
Pennsylvania state law requires appeal procedures for certain commercial insurances. They differ from Medical Assistance requirements.
If your patient has commercial insurance and Medical Assistance, and the problem is with the coordination of these coverage types, have the patient call the Pennsylvania Health Law Project.
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