Medical Neessity Form PDF Details

Do you have a medical necessity form and don't know how to fill it out? You're not alone. Many people find that understanding the information on these forms is confusing, especially given all of their intricate legalities. Thankfully, we've got some tips for deciphering medical necessity, as well as a list of critical points to keep in mind when filling out your form accurately. Read on and learn more about important topics like correctly identifying codes, providing complete documentation, diagnostic criteria requirements and detailed history!

QuestionAnswer
Form NameMedical Neessity Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical necessity form for medicare dme, medical statements, united health care medical necessity forms, dental medical necessity letter

Form Preview Example

STATEMENT OF MEDICAL

NECESSITY FORM

Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for reimbursement from a health care account when your doctor or other licensed health care provider certifies that they are medically necessary. Your Spending Account™ has developed this form to assist you and your health care provider in providing this information. As an alternative, your provider may also write a letter or prescription, as long as it includes all requirements outlined below.

Dual Purpose Items

When a health care service or product can be used for both medical and general health reasons, it is referred to as “dual purpose”. For these items, you must provide additional information to confirm the expense is medically necessary.

Examples of Items Requiring a Statement of Medical Necessity:

■ Automobile Modifications

■ Humidifiers

■ Support Hose

■ Braille Books and Magazines

■ Lodging

■ Tutoring

■ Breast Pumps

■ Massage Therapy

■ Umbilical Cord Storage

■ Cosmetic Surgery

■ Mattresses

■ Vacuums

■ Dental Implants

■ Prescribed Food

■ Weight Loss Programs

■ Exercise Equipment

■ Sunglasses

■ Wigs

*Note that for over-the- counter medicines purchased after December 31, 2010, you must provide a prescription from an authorized health care provider – the Statement of Medical Necessity may not be substituted for a prescription.

A complete listing of eligible expenses and documentation requirements can be found on the YSA Web site. All items requiring additional documentation, including dual purpose items, can be identified by a “?” on the list of eligible expenses.

Requirements

The Statement of Medical Necessity Form was created to capture all required information needed to prove a product or service is medically necessary.

The following information is required:

■Patient Name

■Specific Diagnosis, Diagnosis Code (ICD-9), or Medical Condition

■Specific Length of Treatment (including a begin and end date)

■Name of particular product or service being prescribed

■Medical provider’s signature

■Date (must be in the current calendar year)

■Statement that the product or service is medically necessary and not for general health or cosmetic purposes

If you choose to have your provider write a letter, it must be on the provider’s letterhead and include the information provided above.

Your Spending Account™ is a trademark of Hewitt Associates LLC.

STATEMENT OF MEDICAL

NECESSITY FORM

P.O. Box 785040

Orlando, FL 32878-5040

Fax: 1-888-211-9900

Account Holder Information

First NameMILast Name

(

)

 

 

 

 

 

 

Daytime Phone Number

 

Employee ID (Optional)

 

Employer

Instructions

To have your claim approved, you must submit 1) this completed form, 2) a claim form, and 3) a detailed receipt or Explanation of Benefits from your Medical Insurance Provider. Once received, Your Spending Account will typically process your claim within ten days.

Sending Your Claim to Your Spending Account™

Fax:

1-888-211-9900

 

 

 

 

 

 

Mail:

Your Spending Account™

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P.O. Box 785040

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orlando, FL 32878-5040

If faxing, be sure to place the claim form before your itemized receipts and Statement of Medical Necessity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To Be Completed By A Licensed Practioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name

 

 

 

 

 

 

 

 

Diagnosis, Diagnosis Code (ICD-9), or Specific Medical Condition

 

 

 

/

 

/

 

to

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Length of Recommended Treatment (MM/DD/YYYY)—may not extend beyond the current plan year or 12 months whichever is less. “To present” and “indefinitely” will not be accepted, as they are not definitive dates.

Specific Product or Service Used to Treat Diagnosis—please list each item separately (Note: OTC medicines and drugs purchased after 12/31/2010 require a prescription)

*Your Spending Account’s role is to confirm the proper documentation is submitted for reimbursement under the Plan and is not to determine whether the treatment prescribed by your health provider is medically necessary. The form will be reviewed for completeness only.

Licensed Practioner Certification

By my signature below, I certify that this service or product is medically necessary to treat the medical condition described above and is not in any way for general health or cosmetic purposes.

 

Provider Signature

Date

 

 

 

 

 

 

Employee Certification

 

 

 

By my signature below, I certify that:

 

 

 

■ The primary reason for this expense is to treat the medical condition above, and

 

 

 

■ I would not incur this expense but for the medical condition

 

 

 

 

 

 

 

 

Employee Signature

Date

 

 

 

 

 

How to Edit Medical Neessity Form Online for Free

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Step 1: Open the PDF in our editor by pressing the "Get Form Button" in the top area of this page.

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It's simple to complete the pdf with this practical guide! Here is what you have to do:

1. First, while filling out the statement product items, start in the page that has the following fields:

Step # 1 for completing medical necessity form for medicare dme

2. After this selection of blank fields is filled out, proceed to enter the applicable information in these: To present and indefinitely will, Specific Product or Service Used, require a prescription, Your Spending Accounts role is to, By my signature below I certify, way for general health or cosmetic, Provider Signature, Employee Certification, Date, By my signature below I certify, Employee Signature, and Date.

Stage no. 2 for submitting medical necessity form for medicare dme

Regarding Employee Signature and Provider Signature, be certain that you don't make any mistakes in this current part. The two of these could be the most important ones in this file.

Step 3: Be certain that the details are accurate and click "Done" to continue further. Join FormsPal now and easily get statement product items, available for downloading. Each change made is handily saved , which means you can change the pdf later if required. Here at FormsPal.com, we endeavor to guarantee that all of your details are kept secure.

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