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    TC-4313-062110 OTC Letter of Medical Necessity

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    A letter of medical necessity is required for reimbursement of over-the-counter healthcare expenses from a plan beginning January 1, 2011. The letter must be submitted each year and whenever a treatment plan changes. It requires information about the participant and patient, and certification from the attending physician about the medical necessity of the treatment plan, including start and anticipated end dates, and details of the treatment, medicines, or supplies. The physician must confirm the treatment plan is medically necessary and not for cosmetic or general health reasons.

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    TC-4313-062110 OTC Letter of Medical Necessity

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    kjs-scribd4766
    69 views1 page
    A letter of medical necessity is required for reimbursement of over-the-counter healthcare expenses from a plan beginning January 1, 2011. The letter must be submitted each year and whenever a treatment plan changes. It requires information about the participant and patient, and certification from the attending physician about the medical necessity of the treatment plan, including start and anticipated end dates, and details of the treatment, medicines, or supplies. The physician must confirm the treatment plan is medically necessary and not for cosmetic or general health reasons.

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    A letter of medical necessity is required for reimbursement of over-the-counter healthcare expenses from a plan beginning January 1, 2011. The letter must be submitted each year and whenever a treatment plan changes. It requires information about the participant and patient, and certification from the attending physician about the medical necessity of the treatment plan, including start and anticipated end dates, and details of the treatment, medicines, or supplies. The physician must confirm the treatment plan is medically necessary and not for cosmetic or general health reasons.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    69 views1 page

    TC-4313-062110 OTC Letter of Medical Necessity

    Uploaded by

    kjs-scribd4766
    A letter of medical necessity is required for reimbursement of over-the-counter healthcare expenses from a plan beginning January 1, 2011. The letter must be submitted each year and whenever a treatment plan changes. It requires information about the participant and patient, and certification from the attending physician about the medical necessity of the treatment plan, including start and anticipated end dates, and details of the treatment, medicines, or supplies. The physician must confirm the treatment plan is medically necessary and not for cosmetic or general health reasons.

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    of 1

    Letter of Medical Necessity

    To be reimbursable through your Plan, some healthcare reimbursement


    requests require additional information. Eective 1/1/2011, this includes
    Over-The-Counter (OTC) expenses that fall under the category of
    medicines and drugs (with the exclusion of insulin).
    A prescription or Letter of Medical Necessity must be submitted for such expenses. A new
    prescription or Letter must be submitted each Plan Year in which you request reimbursement of
    prescribed items or services, or any time the treatment plan changes.
    For each individual in your household for whom you purchase healthcare expenses, we ask that
    you complete Section I of this form; the attending physician should complete Sections II and III.
    Submit the completed form(s) to TASC with each Request for Reimbursement. (If more space is
    required please complete another form.)

    SECTION 1
    __________________________________________________________________
    Participant Name (Last, First, M) (PLEASE PRINT)

    ____________________________________
    12-Digit TASC ID Number

    __________________________________________________________________
    Participants Employer/Company Name (PLEASE PRINT)
    __________________________________________________________________
    Patients Name (PLEASE PRINT)

    SECTION II
    I am currently treating ________________________________________________________ for the following:
    (Patients Name)
    1. Treatment Plan: ___________________________________________________________________________________________
    Start Date of Treatment: _____/_____/_____ Anticipated Last Date of Treatment: _____/_____/_____
    Medical treatment, medicines, drugs, service, procedure, equipment or supply: ________________________________________
    _________________________________________________________________________________________________________
    2. Treatment Plan: ___________________________________________________________________________________________
    Start Date of Treatment: _____/_____/_____ Anticipated Last Date of Treatment: _____/_____/_____
    Medical treatment, medicines, drugs, service, procedure, equipment or supply: ________________________________________
    _________________________________________________________________________________________________________
    3. Treatment Plan: ___________________________________________________________________________________________
    Start Date of Treatment: _____/_____/_____ Anticipated Last Date of Treatment: _____/_____/_____
    Medical treatment, medicines, drugs, service, procedure, equipment or supply: ________________________________________
    _________________________________________________________________________________________________________

    SECTION III
    I hereby certify that the treatment plan(s) listed above is medically necessary to treat the ailment or medical condition listed above.
    This treatment plan is neither for cosmetic reasons nor for general health and well-being.
    __________________________________________________________________
    Physician Name (PLEASE PRINT)

    _____/_____/_____
    Date

    __________________________________________________________________
    Physician Signature

    TASC, 2302 International Lane, Madison, WI 53704-3140


    800-422-4661 Fax 608-245-3623 www.tasconline.com

    TC-4313-062110

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