Medical Necessity

WHO can write a letter AFTER surgery to the insurance company to prove medical necessity? Who is qualified? Our case manager only sees the patient after surgery and another NP sees the patient prior to surgery to do the H&P. Does the surgeon have to do it? (I sure hope not.) Can the NP do it and if so, which one should do it? What should the letter contain? Thanks so much for any help anyone can give.

Anyone

I review charts for an insurance company and I review whatever is sent- patient appeals (usually not much help since it is a passionate appeal, not a scientific one), physician letters, PA, letters, therapist letters, etc. The best is whoever can give the best rationale for the procedure/equipment. References help. Of course for most decisions I look at national standards, guidelines, etc to make a determination. Unusual things belong at universities where there can be controlled trials to prove efficacy.

Thanks!!!

Thanks so much for your answer. Can I write the letter as an RN or should I get the surgeon to sign it. I looked up all the things I need to include according to Tennessee law. If I can't sign it, can an NP? Have a good evening and thanks again!

Don't know about the law

but if the doc will sign, it has a little more weight and if the doc is the one not getting paid, she should be willing to sign it to get paid, even if you wrote it. And who better than the doc to know the indications for the surgery? And be sure the info is pertinent- I have seen form letters from offices that have fill in the blanks that carry no weight at all...