According to the Internal Revenue Service (IRS), some healthcare services and products are only eligible for reimbursement through your HRA when your doctor or provider certifies that they are medically necessary.

Take Command has developed this form to assist you and your healthcare provider in providing the information we need to process your claim. Your provider must indicate:

• patient’s specific diagnosis (with CPT code is best!)

• the specific treatment needed

• the start and end dates of treatment

• certification that the treatment is medically necessary

Your provider can also submit a statement on their letterhead, if the letter includes all of the information on this form, including the certification of medical necessity.

By submitting this letter of medical necessity, you certify that the expenses you are claiming are a direct result of the medical condition described, and you would not incur the expenses you are claiming if you were not treating this medical condition.

You only need to submit this letter with the first claim you submit for the service or product. Your letter of medical necessity will only be valid for one year from the date that the physician signed the document, unless the letter specifically states that the treatment is required for a shorter amount of time. There are instances where a letter of medical necessity is only valid for a one-time purchase of a product or service.

You must submit a new letter of medical necessity each plan year — they cannot be approved indefinitely.

Submitting this form does not guarantee that the expense will be reimbursed. Your provider can use the following guidelines when completing a letter of medical necessity:

• The diagnosis that has led to the medical need must be very specific. For example, “back pain” is not specific; “lumbar spinal stenosis with herniated disc at L3” is specific.

• The recommended treatment must be named and described in detail. “Calcium supplementation” is not specific; “800 IU of Vitamin D and 1200 mg of Calcium supplements each day by mouth for the next 6 months to alleviate symptoms of hypocalcemia” is.

• Your provider must state a specific treatment period (with clear start and end dates). Lifetime or indefinite lengths of treatment will not be approved.

• Your licensed provider must complete, sign and date the form.

Typical items that need a letter of medical necessity are

Letter of Medical Necessity Form