Denied: Not Medically Necessary
Too often insurance companies raise doubts about whether or not a patient’s treatment is “medically necessary.”
Insurers may deny claims or withhold authorization by asserting that the treatment is “not medically necessary.” If you’re thinking, “doesn’t the treating clinician (psychiatrist, psychologist, other medical professional) know better what’s medically necessary?”, you’re right.
Action Plan
A medical necessity letter is “[the] authoritative voice of a psychiatrist [or other clinician], backed by the law, [that] can push insurance companies to do the right thing.” So wrote Mark Moran in the Psychiatric News article “Medical-Necessity Letters Written By Psychiatrists Can Be Decisive.”
Clinicians should support access to insurance coverage with a “medical necessity letter” documenting their judgment and experience.
A medical necessity letter from your clinician can be provided to an insurer any time you will have insurance claims that you may be concerned will be denied.
If you have already received a denial of “not medically necessary,” it is often worthwhile to ask an insurer customer service rep what alternative care they are recommending and why. This information may be helpful guidance in the request to your clinician for a medical necessity letter. As always, note the customer service rep name and specific information they provided.
Updated medical necessity letters may be appropriate as the patient’s indicated treatment plan changes. Such an update can reference any previous letters and summarize the changes in clinical assessment and medically-necessary course of treatment.
Getting Going
Who knows best whether your care (or care for a family member) is “medically necessary” or not? Answer: the clinician who takes care of the patient knows best.
Ask your clinician to write a medical necessity letter.
- Share this Template and instructions
- Share this article from the Journal of Psychiatric Practice article that may help your clinician understand the value of these letters when dealing with insurance companies.
A copy of the final letter from your clinician can then be provided to your insurer using this cover letter template.
Provide the letter by fax or certified mail to have documentation that it was received.
After you have submitted the medical necessity letter to your insurer, contact an insurer customer service rep to try resolving the denial, using these talking points:
- “I received a denial for “not medically necessary” on [date] and provided a letter of medical necessity to you on [date].”
- “Please confirm in writing that the claim submitted is medically necessary and will be covered by my insurance plan.”
- “If this cannot be confirmed while on the phone, please confirm coverage within 3 business days.”
- “This is not an appeal. This is a request for correction of an improper denial.”
Be sure to document the name of the insurer customer service rep and date of the call.
If this does not result in a timely resolution, then see “Filing a formal complaint with your insurer” for a next step.
Why file a complaint?
- The goal of filing a “formal complaint” is to escalate an issue towards overcoming whatever obstacle is blocking access to care.
- Filing a formal complaint with your insurer may be helpful (even required) before additional actions, such as filing a complaint with a state insurance regulator.
What a complaint is not?
- A “formal complaint” is NOT an appeal.
- If you are asked whether you want to file an appeal, your response should be: “No, I want to file a formal complaint. This is not an appeal.”
