Build your case
Work with your doctor
Get a letter of medical necessity, ask for a peer-to-peer call, and make it easy for the office to help.
Do this today
- Use the tool: Doctor letter kit Build a short note asking your doctor for a letter of medical necessity, with an outline they can work from.
- Read: How to ask your doctor for a letter of medical necessity 5 minute read. Make it easy for your doctor's office to write a letter that answers the plan's reason for denying your care. Covers who to ask, what to hand over, when, and what to do if the office says no.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- A letter of medical necessity is your doctor's own explanation of why you need the care. Only your doctor can say what is true about your condition.
- Ask early, in writing as well as in person, and give the office the denial notice, the plan's criteria and a send-by date.
- If a physician who knows your condition says your claim is urgent, the plan must treat it as urgent.
- Your part is the paperwork, the facts about daily life and the follow-up. Your doctor's part is the medical statements.
Read the full guide: How to ask your doctor for a letter of medical necessity
More guides, tools and letters
More guides, tools, letters 15
Guides
- How to ask your doctor for a letter of medical necessity
Make it easy for your doctor's office to write a letter that answers the plan's reason for denying your care. Covers who to ask, what to hand over, when, and what to do if the office says no.
- Peer-to-peer review and how to prepare your doctor
A peer-to-peer review is a phone call between your doctor and the plan's reviewing doctor. It is usually worth asking for early, but availability and timing vary by plan. Here is how to ask and prepare.
- What a strong letter of medical necessity contains
A checklist for the letter your doctor writes, so it answers the plan's stated reason, uses the plan's own criteria, and gives the reviewer the facts needed to decide. For you to check the draft against.
Tools
- Tool
Doctor letter kit
Build a short note asking your doctor for a letter of medical necessity, with an outline they can work from.
Letters and scripts
- Letter or script
Certification of urgency (for your clinician)
A short letter in a physician's voice stating that the standard time frame could seriously harm the patient, so the plan must treat the claim or appeal as urgent and decide within 72 hours. Every clinical statement is a blank for the physician to complete.
- Letter or script
Letter of medical necessity (for your clinician to adapt)
A letter in your clinician's voice that explains the diagnosis, what has been tried, why the denied care is medically necessary for you, and what is likely to happen without it. Every clinical statement is a blank for the clinician to complete.
- Letter or script
Note to your doctor's office
A short, courteous note to your doctor's office that says exactly what you need for your appeal, whether that is a letter, records, a call to the plan or a billing check, and by what date.
- Letter or script
Off-label or experimental use letter (for your clinician)
A letter in your clinician's voice that responds to an experimental, investigational or off-label denial with the clinical reasons and the evidence for this patient. Every clinical statement is a blank for the clinician to complete.
- Letter or script
Out-of-network necessity letter (for your clinician)
A letter in your clinician's voice explaining why in-network care cannot meet the patient's needs, so the plan should cover an out-of-network provider. Every clinical and network statement is a blank for the clinician to complete.
- Letter or script
Peer-to-peer call brief (for your clinician)
A one-page set of notes in your clinician's voice for a call with the plan's reviewing doctor: the three points to make, the questions to ask and what to record. Every clinical statement is a blank for the clinician to complete.
- Letter or script
Phone script: ask for a peer-to-peer review
What to say to your doctor's office and your plan to ask for a call between your doctor and the plan's reviewing physician.
- Letter or script
Phone script: three-way call with your provider
How to bring your doctor's office onto a call with your plan so that both sides hear the same facts and agree on what happens next.
- Letter or script
Step therapy exception letter (for your clinician)
A letter in your clinician's voice asking the plan to skip a required first-try drug because it has failed, is unsafe or is otherwise not right for you. Every clinical statement is a blank for the clinician to complete.
Programs and services
- Program or service
Crohn's & Colitis Foundation appeal letter library
Customizable appeal letters for Crohn's disease and ulcerative colitis treatments, tests and dose changes, including a request to use a biologic without first failing other drugs. Written for the doctor's office to edit.
From Crohn's & Colitis Foundation
- Program or service
KFF Health News: seven tips for fighting a health insurance denial
A news article with seven tips for fighting a prior authorization denial, including knowing your plan type, working with your provider, staying organized, and asking for help. Written by a reporter, not by an agency.
From KFF Health News
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
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