List of Sample Letters:
These sample letters can be used in various circumstances you may encounter that require you to communicate with insurance companies. Originating from real-world experiences of numerous families, these letters were developed and used by individuals facing similar situations.
When communicating with insurance providers, it is important to maintain a polite and professional tone even if you get frustrated so you are able to get your message across. It is okay if you get emotional as insurance companies get calls all day long regarding consumer’s needs. It is important for you to highlight the critical nature of the situation and what necessitates careful consideration.
Request that copayment for psychiatrist’s services be adjusted to reflect the medical copay rate, as the treatment involved medication management rather than psychotherapy. This may lead to a reduced copayment amount.
Outcome: Adjustments can be made so that the family is billed for the medical copay. Remember, the psychiatrist must use the proper billing code.
Date:
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Dear [NAME],
Thank you for assisting me with my [child/loved one’s] medical care. As you can imagine, this process is emotionally draining on the entire family. However, the cooperation of the staff at [INSURANCE COMPANY NAME] makes it a little easier.
At this time, I would like to request that [INS. CO.] review the category that [Dr. NAME’s] services have been placed into. It appears that I am being charged a copay for [Dr. NAME’s] treatment as a mental health service when in reality [he/she/they] provide [PATIENT NAME] with pharmacologic management for their neuro-bio-chemical disorder. This consultation is for medical purposes. Please review this issue and kindly adjust past and future consultations.
Thank you in advance for your cooperation and assistance.
Sincerely,
[YOUR NAME]
Cc: [list the people in the company you are sending copies to]
Request to convert the number of hospital days the patient is eligible to receive to counseling sessions when the insurance company denied continued coverage of counseling sessions. Remember, just because you are using outpatient services does not mean that you cannot take advantage of benefits for a more acute level of care if your loved one is eligible for that level of care. The insurance company only knows the information you supply, so be specific and provide support from the treatment team!
Outcome: 10 Hospital days were converted to 40 counseling sessions.
Date:
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Case #
Dear [NAME]:
This letter is in response to [insurance company name’s] denial of continued counseling sessions for my [child/loved one]. I would like to appeal this decision because [PATIENT NAME] continues to meet the American Psychiatric Association’s clinical guidelines criteria for Residential treatment/Partial hospitalization, which is the standard of care. [His/Her/Their] primary care provider, [Dr. NAME], supports [his/her/their] need for this level of care (see attached – Sample Letter #3 provides an example of a physician letter). Therefore, although [PATIENT NAME] chooses to receive services from an outpatient team, [he/she/they] require an intensive level of support from that team, including ongoing counseling, to minimally meet their needs. I request that you correct the records re: [PATIENT NAME’s] level of care to reflect their needs and support these needs with continued counseling services, since partial hospitalization/residential treatment is a benefit [he/she/they] are eligible for and requires.
I am enclosing a copy of the APA guidelines and have noted [PATIENT NAME’S] current status. If you have further questions you may contact me at: [PHONE#] or [Dr. NAME] at: [PHONE#].
Thank you in advance for your cooperation and prompt attention to this matter.
Sincerely,
[YOUR NAME]
Cc: [Case manager]
[Ins. Co. Medical manager]
Letter to a managed care plan to seek reimbursement for services that the patient received when time was insufficient to obtain pre-authorization because of the serious nature of the illness and the need to deal with it urgently.
Remember: you need to research the professionals available through your plan and local support systems. In this case, after contacting their local association for eating disorder experts, the family that created this letter realized that no qualified medical experts were in their area to diagnose and make recommendations for their child. Keep in mind that you need to seek a qualified expert, and not a world-famous expert. Make sure you provide very specific information from your research.
Outcome: Reimbursement was provided for the evaluating/treating psychiatrist visits and medications. Further research and documentation were required to seek reimbursement for the treatment facility portion.
DATE
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Case #
Dear [NAME]:
My [child/loved one] has been under treatment for [name the eating disorder and any applicable co-existing condition] since [month/year]. [He/She/They] were first seen by [Insert TYPE OF PROVIDER (i.e., the college health clinic, their primary care physician or specialist)] [at UNIVERSITY NAME or Dr. NAME] and then referred for treatment that was arranged through [INS. CO.]. At the end of the semester, I met with my [child/loved one] and [his/her/their] therapist to make plans for treatment over the summer. At that time, residential treatment was advised, which became a serious concern for us.
We then sought the opinion of a qualified expert about this advice. I first spoke to [PATIENT NAME’S] primary physician and then contacted an eating disorders organization for consultation and resources. No qualified expert emerged quickly from the community of our [INS. CO.] network providers. In my research to identify someone experienced in eating disorder evaluation and treatment, I discovered that [insert Dr.NAME at HOSPITAL in LOCATION] was the appropriate person to contact to expedite plans for our [child/loved one]. Dr. [NAME] was willing to see [him/her/them] immediately, so we made those arrangements.
As you can imagine, this was all very stressful for the entire family. Due to the medical complications of eating disorders, and the need for continuity of care was imperative, so we went ahead with the process and lost sight of the pre-approval needed from [INS. CO.]. I am enclosing the bills we paid for those initial visits for reimbursement. [PATIENT NAME] was consequently placed in a residential treatment program in the [LOCATION] area and continues to see Dr. [NAME] through arrangements made by [INS. CO.].
Also, at the beginning of [PATIENT NAME]’s treatment, some confusion existed about medications necessary for them during this difficult/acute care period. At one point payment for one of [his/her/their] medications was denied even though the treatment team recommended it, and it was prescribed by [his/her/their] primary care physician, Dr. [NAME]. I spoke to a [INS. CO.] employee [NAME] at [PHONE #] to rectify the situation, however, I felt it was a little too late to meet my timeframe for visiting [PATIENT NAME], so I paid for the Rx myself and want reimbursement at this time. If you have any questions, please speak to [employee name].
Thank you in advance for your cooperation. I’d be happy to answer any further questions and can be reached at: [PHONE]
Sincerely,
[YOUR NAME]
To continue being covered by insurance while attending college less than full-time so that the student can remain at home for a semester due to the eating disorder. Note: When a student is insured through their school and does not have insurance through their parents plan, if they do not register on time at the primary university at which they have been enrolled, insurance is automatically terminated at that time. Automatic termination can cause an enormous amount of paperwork if not rectified IMMEDIATELY.
The first letter informs the insurance company of the student’s current enrollment status in a timely fashion, and the second letter responds to the abrupt and retroactive termination. Students affected by an eating disorder may be eligible for a medical leave of absence from college for up to one year — so you may want to inquire about that at the student’s college.
Outcome: The student was immediately reinstated as a less than full-time student.
DATE
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Case #
Dear [NAME]:
We spoke the other day regarding my [child’s/loved one’s] enrollment status. I am currently following up on your instructions and appreciate your assistance in explaining what to do. [Dr. NAME] is sending you a letter that should arrive very soon about [PATIENT NAME’s] medical status that requires [him/her/them] to reduce the number of classes they will be able to take this fall. When [PATIENT NAME’s] completes re-enrollment at [UNIVERSITY NAME] (which is not possible to do until the first day of classes, [DATE]), [he/she/they] will have the registrar’s office notify you of [his/her/their] status.
At this time, [PATIENT NAME] plans to be a part-time student at [UNIVERSITY] for the [DATE] semester and plans to return to [UNIVERSITY] in [DATE], provided their eating disorder stabilizes. If all goes well, [he/she/they] may be able to graduate with their class and complete [his/ her/their] coursework by the [DATE] in spite of the medical issues. Please feel free to get answers to any questions regarding these plans from [PATIENT NAME’S academic advisor Mr./Ms. NAME], whom [PATIENT NAME] has given written permission in a signed release to speak to you. This advisor has been assisting my [child/loved one] with [his/her/their] academic plans and is aware of [his/her/their] current medical status. The advisor’s phone number and email are: [PHONE #/ email].
Please feel free to contact me at [PHONE #] if you have any questions or need any further information. Thank you for your assistance.
Sincerely,
[YOUR NAME]
Cc:
Letter from doctor describing any medical complications your child has had, the doctor’s recommendations for treatment, and the doctor’s prediction of outcome if this treatment is not received. This is a sample physician letter that parents can bring to their child’s doctor as a template to work from.
DATE
To: [NAME OF INSURANCE COMPANY MEDICAL DIRECTOR]:
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Case #
Dear [NAME],
We are writing this letter to summarize our treatment recommendations for [patient name]. We have been following [patient name] in our program since [DATE]. During these past [NUMBER years], [patient name] has had [NUMBER] hospitalizations for medical complications of [insert medical complications, i.e., malnutrition, profound bradycardia, hypothermia, orthostasis]. Each of the patient’s hospital admissions are listed below [list each and every one separately]:
In all, [PATIENT NAME] has spent [NUMBER] days of the past [NUMBER years] in the hospital due to complications of [his/her/their] [insert TYPE of EATING DISORDER (spelled out)], which has resulted in [insert identified complication(s)]. [His/Her/Their] course has been complicated by the following medical issues:
Despite receiving intensive outpatient medical, nutritional, and psychiatric treatment, [patient name’s] medical condition has continued to deteriorate with [describe how symptoms/signs have worsened, i.e., consistent weight loss, white blood cell count and serum protein and albumin levels have been steadily decreasing etc.] since DATE.
Given this history, prior levels of outpatient care that have failed, and [his/her/their] current grave medical condition, we recommend that [PATIENT NAME] urgently receive more intensive psychiatric and nutritional treatment that can be delivered only in a residential treatment program specializing in eating disorders. We recommend a minimum 60- to 90- day stay in a tiered program that offers: acute residential and transitional components focusing on adolescents and young adults with eating disorders (not older patients, if applicable). [PATIENT NAME] requires intensive daily psychiatric, psychologic, and nutritional treatment by therapists well-trained in the treatment of this disease. Such a tiered program could provide the acute residential treatment that [he/she/they] so desperately needs so [he/she/they] can show that [he/she/they] can maintain any progress in a transitional setting. We do not recommend treatment in a non-eating disorder-specific behavioral treatment center. [PATIENT NAME]’s severe [identified eating disorder diagnosis] requires subspecialty-level care and includes a multidisciplinary team including, psychiatrist, medical provider, registered dietician, and psychotherapist to address and treat the eating disorder. Examples of such programs would include [name facilities].
Eating disorders are deadly diseases with the second highest mortality rate of any psychiatric illness behind opiate addiction. In addition, up to 20% of patients with an eating disorder will develop a severe lifelong course of the disease. We believe that without intensive treatment in a residential program, [patient’s name and condition], and the medical complications that it causes, will continue to worsen causing [him/her/them] to be at significant risk of developing lifelong [identify eating disorder diagnosis] or dying of the disease. We understand that in the past, your case reviewers have denied [patient] this level of care. This is the only appropriate and medically responsible care plan that is recommended. We truly believe that to offer a lesser level of care is medically negligent. We trust that you will share our grave concern for [PATIENT NAME]’s medical needs and approve the recommended level of care to assist in [his/her/their] recovery.
Thank you for your thorough consideration of this matter. Please feel free to contact us with any concerns regarding [patient’s] care.
Sincerely,
[PHYSICIAN NAME]
Cc: [YOU]
“Discussion” with the insurance company about residential placement when the insurance company suggests that the patient needs to fail at lower levels of care before being eligible for residential treatment. In a telephone conversation, the parents asked the insurance company to place a note in the patient file indicating the insurance company was willing to disregard the American Psychiatric Association guidelines and recommendations of the patient’s treatment team and take responsibility for the patient’s life. (SEND BY CERTIFIED MAIL!)
Outcome: Shortly thereafter, the parents received a letter authorizing the residential placement.
DATE
To: [NAME OF CEO]
INS. CO. NAME & ADDRESS (use the headquarters)
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB (Date of Birth)
Insurance ID#
Case #
Dear [NAME OF INSURANCE COMPANY CEO]:
Residential placement services for eating disorder treatment have been denied for our [child/loved one] against the recommendations of a qualified team of experts consistent with the American Psychiatric Association’s evidence-based clinical practice guidelines. Full documentation of our child’s grave medical condition and history and our attempts to obtain coverage for that care is available from our case manager [name]. At this time, I would like you to put in writing to me and to my [child’s/loved one’s] case file that [INS. CO.] is taking complete responsibility for my [child’s/loved one’s] life.
Respectfully,
[YOUR NAME]
Cc: [CASE MANAGER, NATIONAL MEDICAL DIRECTOR (get the names for both the medical and behavioral health divisions), NATIONAL MEDICAL DIRECTOR – Behavioral Health]