Appeal Letter to MCO When Treatment is Denied (Not Covered Service)

APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED ON GROUNDS THAT IT IS NOT A “COVERED MEDICAL SERVICE”

Chairperson

Utilization Review Committee

RE:     (Patient Name)

Patient ID Number

Dear:

On (Date), I prescribed (Test/Procedure) for (Patient’s Name). On (Date), you denied authorization of payment for that (Test/Procedure) on the grounds that it was not a covered medical service. I request that you reconsider your determination for the following reasons:

(List Reasons That Demonstrate Why the Test/Procedure is a Covered Service)

In my medical judgment, a (Test/Procedure) is a very important part of my overall care of (Patient’s Name). (Patient’s Name) suffers from (Describe Condition). In addition to being a covered benefit, the (Test/ Procedure) is necessary to (Describe Why Necessary). Failure to perform the (Test Procedure) could result in the following problems:

(Describe Problem)

For these reasons, I urge you to reconsider your denial of payment authorization for the procedure I have prescribed. Enclosed are pertinent medical records supporting my recommendation.

By copy of this letter to (Patient’s Name), in my best medical judgment, I suggest that he/she obtain the (Test/Procedure), despite your denying payment authorization.

Yours truly,

(Your Name)

cc: (Patient’s Name)

Appeal Letter to MCO When Treatment is Denied (Not Medically Necessary)

APPEAL LETTER TO MCO WHEN TREATMENT HAS BEEN DENIED ON GROUNDS THAT IT IS NOT “MEDICALLY NECESSARY”

Chairperson

Utilization Review Committee

RE:     (Patient Name)

Patient ID Number

Dear:

On (Date), I prescribed (Test/Procedure) for (Patient’s Name). On (Date), you denied authorization of payment for that (Test/Procedure) on the grounds that it was not medically necessary. I request that you reconsider your determination for the following reasons:

(List reasons that demonstrate why the test is medically necessary)

In my medical judgment, a (Test/Procedure) is a very important part of my overall care of   (Patient’s Name). (Patient’s Name) suffers from (Describe Condition). The (Test/Procedure) is necessary to (Describe Why Necessary). Failure to perform the (Test/Procedure) could result in the following problems:

(Describe problem)

For these reasons, I urge you to reconsider your denial of payment authorization for the procedure I have prescribed. Enclosed are pertinent medical records supporting my recommendation.

By copy of this letter to (Patient’s Name), in my best medical judgment I suggest that he/she obtain the (Test/Procedure), despite your denying payment authorization.

Yours truly,

(Your Name)

cc: (Patient’s Name)

Referral Form for Managed Care Patients

REFERRAL FORM FOR MANAGED CARE PATIENTS

Date:                                                  

Dr.                                                        has referred you to Dr.                                              

Phone:                                                

This referral is:

                                          Emergency

                                           Urgent (24-48 hours)

                                           Timely (1-2 weeks)

                                           When convenient

This appointment will have to be made for you by your primary care physician,

Dr.                                                       , who has been notified.  If there are any problems scheduling this appointment, please contact this office.

For office use only:

Outcome:                                                                                                                                           

(Original to patient. Copy to chart.)

Noncompliant Patient Missed or Cancelled Appointment (Sample Letter)

NOTE:  This sample letter is provided as a guideline only and should be modified according to the situation. Be sure to place a copy of the letter in the patient’s chart.  If the patient’s condition warrants a receipt, ask for delivery verification (DV).  DV is cheaper than certified, and does not require the patient’s signature.  Instead, the mail carrier verifies that the letter was delivered.   If DV is not available, send the letter certified and through the regular mail.  Place the letter and the verification or signed return receipt in the patient’s chart.

[SENT WITH DELIVERY VERIFICATION OR CERTIFIED MAIL-RETURN RECEIPT REQUESTED (send also through regular mail)

only if patient risks serious vision loss, otherwise use regular mail]

(Date)

Dear (Patient):

You have canceled your follow-up appointment on (date) without rescheduling. We were unable to reach you by telephone.

Continued care is essential to the health of your eyes. You have an eye condition which will worsen without proper care (If the patient has a condition that requires specific care, state the care AND the consequences of  no care in clear, patient-friendly language.  If the patient has a condition that needs regular follow-up, state the frequency and urgency of the follow-up, AND state the consequences of not getting the follow-up at the recommended time in clear, patient-friendly language.)  Permanent damage may occur, resulting in visual loss or blindness. Kindly realize this letter is not meant to alarm you. We only wish to inform you of the seriousness of your condition, as it was also explained during office visits, and encourage you to seek proper care.

Please contact our office as soon as possible to reschedule.

With best regards,

(Physician’s Signature & Name)

Contact Lens Expired Prescription (Sample Letter)

LETTER TO A PATIENT REQUESTING MEDICAL RECORD WHICH CONTAINS EXPIRED CONTACT LENS PRESCRIPTION

(Physician’s Letterhead)

(date)

Dear (Patient):

You have provided me with a signed, written request for a copy of your medical record. Your medical record contains specifications of contact lenses based on a previous examination and contact lens fitting. The contact lens specifications in your records were valid at the time I prescribed your contact lenses. However, a comprehensive ophthalmic examination is necessary prior to obtaining new lenses. Additional testing and diagnostic lens fitting evaluation is necessary to determine your new contact lens prescription. Follow-up exams are necessary because lens design modifications may be needed before I can arrive at a final contact lens prescription.

In addition, there are eye conditions that may have developed since your last examination that may keep you from wearing contact lenses. Some of the conditions that might keep you from wearing contact lenses are: frequent eye infections; severe allergies; and dry eye (improper tear film). An ophthalmologist is the physician specialist who can diagnose and treat conditions that may prevent optimal contact lens wear.

There are also certain environmental conditions or personal practices that may have changed since your last examination that may prevent you from wearing contact lenses, such as: a work environment that is very dusty or dirty or your improper handling and care of the lenses. An important aspect of contact lens wear is properly wearing, disinfecting, and cleaning the lenses. Even if you have worn contact lenses before, I believe it is important for my office to reevaluate your proper handling and care of the lenses. We can also advise you regarding the use of appropriate cosmetics. Improper use of cosmetics can lead to eye irritation as well as infection.

Please call my office if you would like to schedule an appointment. The health of your eyes is our main concern and should be yours.

Sincerely,

                                                                        , M.D.