Tips and Letter Templates to Use with Insurance Companies
The other day I shared one of the letter templates I give to healthcare providers and parents to communicate with insurance companies. It’s about the bazillionth time this year. I finally realized I need to just post these bad boys on the blog. While these are all free templates for you to use, sometimes parents and providers need some consultation on details within letters. Feel free to reach out to me for help.
At the end are a bonus Top 10 essential tips for communicating with insurance.
Here are several sample letters you can use in a bunch of situations you’ll likely run into when dealing with insurance companies. I’ve used and recommended these letters for years. Keep in mind that a cordial, business communication tone is essential. despite your head wanting to explode with frustration.
Template Letter: Change from Mental Health to Medical Copay Charges
This letter is a request that the copay for the psychiatrist from the patient be changed to a medical copay rate instead of the higher mental health copay, because the psychiatrist was providing medication management, not psychotherapy. You’ll also want to coordinate with the psychiatrist’s office to make sure they use the correct billing codes.
Date:
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Dear [NAME],
Thank you for assisting me with [my loved one’s] medical care. As you can imagine, this process is very emotionally draining on our entire family. However, the cooperation of the fine staff at [INSURANCE COMPANY NAME] makes it a little easier.
At this time, I’d 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 [his/her] treatment as a mental health service when in reality [he/she] provides [PATIENT NAME] with medication management for [his/her] diagnos(is/es). This is exclusively a medical consultation. Please review this issue and kindly make adjustments to past and future consultations.
Thank you in advance for your assistance.
Sincerely,
[YOUR NAME]
Cc: [list the people in the company you are sending copies to]
Template Letter: Request for Counseling Sessions with Inpatient Hospitalization
The need to flex hospital days for counseling sessions. Just because you are using outpatient services does not mean that you cannot take advantage of benefits for a more acute level of care (eg. inpatient) if your child meets medical necessity for that level of care. The insurance company only knows the information you supply, so be specific and provide support from the treatment team.
Date:
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME]:
This letter is in response to [INS. CO.’s] denial of continued counseling sessions for my [daughter/son]. I would like to appeal this decision because [insert PATIENT NAME] continues to meet the American Psychiatric Association’s clinical practice guidelines criteria for Residential treatment/Partial hospitalization. [His/Her] primary care provider, [NAME], supports [his/her] need for this level of care (see attached – [Example of a physician letter is below]). Therefore, although [he/she] chooses to receive services from an outpatient team, [he/she] requires an intensive level of support from that team, including ongoing counseling, to minimally meet [his/her] needs. I request that you correct the records re: [PATIENT NAME’s] level of care to reflect [his/her] needs and support these needs with continued counseling services, since partial hospitalization/residential treatment is a benefit [he/she] is 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]
Template Letter: Request for Reimbursement w/o Prior Authorization
This is a letter to managed care to seek reimbursement for services that your son/daughter received when time was insufficient to obtain pre-authorization (or prior authorization) because of the serious nature of the illness and the need to deal with it urgently.
Make sure to research the providers available through your plan and local support systems. Very often, there are no qualified medical experts in parents’ area to diagnose and make recommendations for their child. Make sure you provide very specific information from your research.
DATE
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME]:
My [son/daughter] has been under treatment for [name the MH disorder and any applicable co-existing condition] since [month/year]. [He/she] was first seen at the college health clinic at [UNIVERSITY NAME] and then referred for counseling that was arranged through [INS. CO.]. At the end of the semester I met with my [son/ daughter] and [his/her] 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 several local therapists. No qualified expert was available from the community of our [INS. CO.] network providers. In my research to identify someone experienced in mental health 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. Dr. [NAME] was willing to see [him/her] immediately, so we made those arrangements.
This was all very stressful for our family. Since continuity of care was imperative, we moved forward with the intake process without awareness of the pre-approval required by [INS. CO.]. I am enclosing the bills we paid for those initial visits for reimbursement. [PATIENT NAME] was consequently placed in a residential setting in the [LOCATION] area and continues to see Dr. [NAME] through arrangements made by [INS. CO.].
Additionally, at the beginning of [his/her] treatment, some confusion existed about medications necessary for [PATIENT NAME] during this acute care period. At one point payment for one of [his/her] medications was denied even though the treatment team recommended it, and it was prescribed by [his/her] primary care physician, Dr. [NAME]. I spoke to a [INS. CO.] employee [insert name] at [PHONE #] to rectify the situation though no reimbursement was provided.
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]
Template Letter: Request for Continuation of Coverage when Not a FT Student
The goal of this letter is to ask your insurance provider to continue insurance for your son/daughter while attending college less than full-time so that they can remain at home for a semester due the eating disorder (or any other psychiatric/psychological diagnosis). When students don’t register on time at the primary university at which he/she has been enrolled, insurance is automatically terminated. 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 mental health diagnoses 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.
DATE
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME]:
I would like to get instructions for how to continue insurance for our son/daughter under our plan while being treated at home for [DIAGNOSIS]. [Dr. NAME] is sending you a letter about [PATIENT NAME’s] medical status that requires [him/her] to reduce the number of classes [he/she] will be able to take this [SEMESTER]. When [he/she] completes re-enrollment at [UNIVERSITY NAME] (which is not possible to do until the first day of classes, [DATE]), [he/she] will have the registrar’s office notify you of her status.
[NAME] will be a part-time student at [UNIVERSITY] for the [DATE] semester and plans to return to [UNIVERSITY] in [DATE], provided [his/her] disorder stabilizes. [He/she] may be able to graduate with [his/her] class and complete [his/ her] 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 [son/daughter] with [his/her] academic plans and is aware of [his/her] 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:
Template Letter: Appeal for Coverage Termination
This is a letter on behalf of your son/daughter is to the enrollment department after coverage was terminated retroactive to a specific date by the insurance company. The scenario I use here is common for many college students struggling with mental health challenges.
DATE
To: NAME OF CONTACT PERSON
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME]:
[NAME] has been receiving coverage from [INSURANCE COMPANY] for treatment of serious medical issues since [DATE]. Which is why we were surprised to receive the attached letter terminating his/her coverage. We have received helpful assistance from [NAME], Case Manager [PHONE#]; [NAME], Mental Health Clinical Director [PHONE#]; and Dr. [NAME], [INS. CO.] Medical Director [PHONE #]. I am writing to describe the timeline of events with copies to the people who have assisted us as noted above.
In [DATE], [ PATIENT NAME] requested a temporary leave of absence from [UNIVERSITY 1 NAME] to study at [UNIVERSITY 2 NAME] for one year. [He/she] was accepted at [UNIVERSITY 2 NAME] and attended the [DATE] semester. At the end of the spring semester [PATIENT NAME’S] medical issues intensified and [PATIENT NAME] returned home for the summer. The summer of [YEAR] has been very complicated for our entire family. The supportive people noted earlier made this time significantly less challenging despite .
At the beginning of August [PATIENT NAME] and the treatment team discussed his/her needs for the fall semester of [YEAR]. As far as our family was concerned, all options [UNIV. 1, UNIV. 2, & several local options full and part-time] needed to be up for discussion to meet [patient name’s] medical needs.
During [PATIENT NAME’s] appointments the first two weeks of August, the treatment team advised [PATIENT NAME] to live at home and attend a local university on a part-time basis for the fall semester. [PATIENT NAME ]plans to return to [UNIV. 1] in [date] as a full-time student. [He/she] has worked with [his/her] [UNIV. 1] advisor since [date] to work out a plan that might still allow [him/her] to graduate with [his/her] class even if [he/she] needed to complete a class or two in the summer of [YEAR]. This decision by [NAME] was difficult but understood to be a necessity for [his/her] treatment.
Following this treatment team decision, I called the enrollment department at [INS. CO. NAME] about the process of notification regarding this change in academic status due to [his/her] current documented medical needs. [INS. EMPLOYEE NAME] stated that I needed to have my child’s primary care physician write a letter supporting these plans. This letter was sent on [DATE] to [INS. EMPLOYEE] and is also enclosed. As soon as [PATIENT NAME’s] fall classes are finalized on [date]’ that information will also be sent to you.
In summary, [PATIENT NAME] intended to be a full-time student this fall until [his/her] treatment team suggested otherwise in the early August. At that time I notified the insurance company. Please assist us in reinstating [him/her] as a policy member. If [his/her] status is not resolved immediately it will generate significant and unnecessary work for all parties involved while also derailing his/her treatment.
I am attaching 1) my previous enrollment notification note; 2) [PATIENT NAME’s] acceptance from [UNIV. 2]; 3) a copy of [PATIENT NAME’S] apartment lease for the year; and 4) [his/her] recent letter to [UNIV. 2] notifying them that [he/she] will be unable to complete the year as a visiting student for medical reasons. Please call me TODAY at [PHONE #] to update me on this issue.
Thank you for your assistance.
Sincerely,
[YOUR NAME]
Cc: [CASE MANAGER, MENTAL HEALTH CLINICAL DIRECTOR, MEDICAL DIRECTOR]
Template Letter: Doctor’s Summary of Services, Prognosis, and Treatment Recommendations
This is a letter from the doctor on their letterhead describing all medical and mental health complications your child has had (I used anxiety disorder for this example), the doctor’s recommendations for treatment, and the doctor’s prediction of outcome if this treatment is not received. In my experience, psychiatrists and doctors appreciate a letter template so all they need to do is add in their specific pieces of information.
DATE
To: [NAME OF INSURANCE COMPANY MEDICAL DIRECTOR]:
INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME],
This letter is a summary of my treatment recommendations for [patient name]. I have been following [patient name] in our program since [DATE]. During these past [NUMBER years], [patient name] has had [NUMBER] hospitalizations for medical/mental health complications of F41.1 Generalized Anxiety Disorder (GAD). Each of the patient’s hospital admissions are listed below [list each one separately]:
- Admission Date – Discharge Date [condition]
[Patient] has spent [NUMBER] days of the past [NUMBER years] in the hospital due to complications of GAD. [Patient name’s] anxiety has been complicated by the following medical issues:
- List each issue and its medical/psychological consequences [eg. significant negative impact on sleep]
Despite receiving intensive outpatient psychiatric and psychological treatment, [patient name’s] anxiety has failed to improve.
Given this history, prior levels of outpatient care that have failed, and [his/her] the current significant toll anxiety is causing on their life including but not limited to ability to complete minimal academic requirements at their university, I recommend that [patient name] receive more intensive psychiatric treatment that can be delivered only in a residential treatment program specializing in anxiety disorders.
I recommend a minimum 30 day stay in a tiered program that offers: intensive residential and transitional components focusing on adolescents and young adults with anxiety disorders (not older patients). [Patient] requires intensive daily psychiatric and psychological treatment by therapists well-trained in the treatment of anxiety. Such a tiered program could provide the intensive residential treatment that [he/she] so desperately needs so [he/she] can show that [he/she] can maintain any progress in a transitional setting and ultimately back at their university. Examples of such programs include [name facilities].
Thank you for your consideration. Please feel free to contact me with any concerns regarding [patient’s] care.
Sincerely,
[PHYSICIAN NAME]
Cc: [YOU]
Template Letter: Appeal after Denial of Higher Level of Care
This letter is a terse request for a higher level of care and that the insurance company take full responsibility for their child’s welfare. I’ve included in this an assumption that the insurance company suggested that the patient has not failed enough at lower levels of care (eg. outpatient therapy) and are therefore ineligible for residential treatment.
During the most recent phone conversation, I’ve also added into the scenario (and recommend you do the same) that the parents asked the insurance company to place a note in their child’s 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. Ouch. For a cherry on top, you could also ask for a similar letter where they disregard the Mental Health Parity and Addiction Equity Act that states insurers are required to provide the same level of support for mental health treatment as medical treatment.
DATE
To: [NAME OF CEO]
INS. CO. NAME & ADDRESS (use the headquarters)
From: YOUR NAME & ADDRESS
Re: PATIENT’S NAME
DOB
Insurance ID#
Case #
Dear [NAME OF INSURANCE COMPANY CEO]:
We respectfully request a formal reconsideration and appeal of your company’s denial for residential treatment for our son/daughter [NAME]. Residential placement services for [DIAGNOSIS] have been denied for our [son/daughter] 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 significant psychiatric and psychological condition, history and our attempts to obtain coverage for that care is available from our case manager [NAME]. I also request that you put in writing to me and to my child’s case file that [INS. CO.] is taking complete responsibility for my [son’s/daughter’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]
Here are my 10 essential tips for communicating with insurance:
- Organize Everything: Create a google doc (or Word Doc) and folder to track ALL communication (dates, names, phone numbers, etc) and docs. Treat this like you are investigating a homicide – leave no evidence undocumented.
- Assume There’s No Coordination: Assume each insurance department does not communicate with the other ones.
- Document EVERYTHING: Insurance companies routinely lose stuff. This is why you need that documentation process I listed above.
- Over Communicate: CC letters to everyone connected to your issue.
- Assume Everything Gets “Lost”: Always provide supporting documents – even if you’ve already sent it. See above – insurance companies ‘lose’ everything.
- Create Paper Trails: Always use a signed delivery receipt. Pro Tip: You will receive confirmation insurance received the letter and when you follow up with them, they will swear they did not receive it.
- Find Humans: Obtain and address the letter to a real human. Sending a letter “To Whom It May Concern” is an easy way for insurance to claim they never received it.
- Schedule Automatic Follow Ups: Follow up all letters with phone calls and document whom you speak to.
- Get Support For Yourself: I’m not even joking. Find a therapist for yourself to deal with the anger, frustration, and overwhelming unfairness you will likely experience while dealing with insurance.
- Outlast Them: Insurance companies have unofficial policies of just needing to outlast their customers. Keep going and let them know you will not give up fighting for coverage, reimbursement, and necessary healthcare they are legally obligated to pay for.