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Medical Necessity Letters: Tips and Templates to Help Your Patients with Insurance Coverage for Mental Health Treatment

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13 years after Congress passed the Mental Health Parity and Addiction Equity Act, mental health clinicians and patients still wrangle with insurance providers to pay for medically necessary—and legally mandated—coverage.  

Writing in the Journal of Psychiatric Practice, four authors* with medical, legal, public-policy, and personal experience in this area provide expert advice as well as letter templates and suggested text that you can access and download for FREE.  

“Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients,” which appears in the July 2021 edition of the journal, offers you: 

  • 8 principles of effective evaluation and treatment of mental and substance use disorders that meet generally accepted standards extracted by Drs. Paul Applebaum and Joseph Parks from the Wit v United Behavioral Health (UBH)/Optum verdict  
  • A detailed overview of how insurers will often base their denials on a lack of “medical necessity,” effectively overruling a clinician’s determination of the proper course of treatment and running counter to the parity act as well as state laws.  
  • An in-depth review of the 4 key elements in an effective medical necessity letter 

In addition, included with the article are three practical and easily reproducible appendices for you to adapt to your specific needs: 

  1. Template for a medical necessity letter, with instructions for use 
  2. Suggested text for inclusion in a medical necessity letter (from the Wit verdict) 
  3. Patient Handout—information to share with your patients regarding additional resources to help them file claims and secure medically necessary coverage they are entitled to 

*“Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients,” appears in the Journal of Psychiatric Practice Vol. 27, No. 4. Its authors are: Joseph Feldman, MBA, Board Member, The Kennedy Forum Illinois; Mark DeBofsky, JD, Member, DeBofsky, Casciari, Sherman, Reynolds, and Adjunct Professor of Law at University of Illinois-Chicago School of Law; Eric M. Plakun, MD, Medical Director/CEO, The Austen Riggs Center, and Founder, American Psychiatric Association Psychotherapy Caucus; and Cheryl Potts, MBA, Executive Director, The Kennedy Forum Illinois. 

Journal of Psychiatric Practice content is normally offered for a fee, but due to the public service nature of this article, the authors have made special arrangements for you to access this important article for free. Click here to download a PDF of the article and its appendices.   

Additionally, clinical and advocacy organizations may further share this information with blog posts, newsletter updates, and website links.  For more information about support in sharing, please contact John Zollinger at john.zollinger@austenriggs.net or 413.931.5816. 

 

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