There will be times when you have to write a letter to get a procedure covered, or therapy covered, or a piece of equipment approved, or an item reimbursed.  Whatever the case is, it is helpful if you know what needs to be included in the letter.  Also, if you write the letter, it is clear in your mind what and why it is needed and you become a better advocate for your child.  Often your child’s physician or therapist will also have to write the letter.  Always keep the original or a signed copy of the letter for your files. An example of an outline for a letter is as follows:

Your name
Your address
City, State, zip code
Home telephone number
Day time telephone number

Date

Company Name you are writing to
Their address
City, State, zip code
Telephone number

                     Re: Your child’s name
                     Insurance Policy number:
                     Diagnosis:
                     D.O.B.:

Dear (it is best to have a name, otherwise To Whom it May Concern:),

I am writing to request _________. My child’s name is _________. He is ______ years old. He is diagnosed with Rubinstein Taybi Syndrome.

Child’s name requires ____________ for _______________. Describe the procedure, the therapy, the medicine, or the equipment (whatever it is that you are requesting). The procedure should be skilled and result in functional changes. Functional changes are changes that are measurable/noticeable that result in your child being able to function better in everyday life. For example, your child being able to use the bathroom independently, or use a communication device to ask a question, or hold a utensil after thumb surgery, all of these are functional changes. It is also helpful if you can describe how it is cost-effective.

Explain how this request will improve your child’s status, especially if it will make a measurable change. State how will this intervention will impact the child’s life and how his life will be different without it. Explain the limits of the child and what he is able to do now. Then discuss how the intervention will make functional, measurable changes. Sometimes it is important to state the obvious. You want to be positive and tell how this request will provide a higher level of independence. It is helpful to use comparison statements such as, currently he is able to do this, but with this intervention he will be able to do this.

If you know the policy’s definition of medical necessity, then explain how this request meets all the criteria. The policy might require a prescription from a doctor, so be sure to include it.

Closing statement. Describe the person and how life is difficult. But with their approval, they are making life better for this person.

Sincerely,


Your name

Points to think about when addressing reimbursement resources

1.       It is important to create a paper trail and keep a copy of all letters that you send. GET IT IN WRITING! You will be amazed at how much paper will be generated.

2.       Progress reports should always show progress. If progress is not being demonstrated and your child’s status remains unchanged, then the intervention will be denied. It is very important to use comparison statements to show progress, e.g. currently, … previously. Give measurable data to show improvement.

3.       State why your child needs skilled services. Explain why the stated frequency and duration are needed.

4.       Do not use too many sophisticated medical terms, the person you are talking to or writing to might not have a medical background.

5.       Do not use abbreviations. Not everyone is familiar with all abbreviations.

6.       State functional goals that are consistent with the evaluation/diagnosis.

7.       Demonstrate how the intervention leads to functional progress.

8.       Write clearly and understandably and state the facts. Do not bog down the reader with unnecessary details. Otherwise, the important facts will be lost. Try to make it short.

9.       When possible type your letters, otherwise write very legibly.

10.   Identify all your pages with your child’s name and the date.

11.   Ask someone to read your letter before you send it, you do not want it to have any mistakes.

12.   Underline very important details.

13.   Services that are not typically covered are: Maintenance care

o        Multiple routine rechecks

o        Screening evaluations

o        Duplicated services

o        Experimental or untried procedures

o        Non-skilled therapy

o        Unreasonable or unnecessarily care

So, if you are trying to get one of the above covered, you will have to provide additional argument as to why it should be covered.

14.  You can always appeal a denial.  Sometimes there are time constraints, if you are not within the stated time frame, they do not have to reply to you.  It is helpful, if you send your letters certified to prove your dates.  If you receive a denial, ask for a letter that states exactly why it was denied.  You can ask for a second opinion.

15.  If you think you might end up with a lawsuit. You should immediately consult with a lawyer who has dealt with this type of problem (not your real estate lawyer or friend down the street). You must submit any documents that you will want the court to see to the insurance company, otherwise they might not be allowed in court or an expert witness might not be allowed to testify.