Need braces? UnitedHealthcare might cover it. But, you often need to prove it’s medically necessary. This means showing it’s not just for looks. You’ll need to explain how it impacts your health.
Getting UnitedHealthcare to approve orthodontia can be tricky. A strong letter is key. It needs to clearly state why braces are essential for your health.
We’ve got you covered! This article provides sample letters. Use them as a guide to write your own. Make the process easier and increase your chances of approval.
Sample Letter To Unitedhealthcare Requesting Medically Necessary Orthodontia
[Your Name]
[Your Address]
[Your Phone Number]
[Your Email Address]
[Date]
UnitedHealthcare
[Insurance Company Address]
**Subject: Request for Medically Necessary Orthodontia – [Patient Name] – [Policy Number]**
Dear UnitedHealthcare,
This letter is to request pre-authorization for orthodontic treatment for my [son/daughter/dependent], [Patient Name], whose policy number is [Policy Number].
[Patient Name] requires orthodontic treatment to correct a severe malocclusion that is impacting [his/her] health and well-being. Specifically, [he/she] suffers from [Describe the specific condition, e.g., severe overbite, open bite, crossbite, impacted teeth. Be specific and use layman’s terms].
This condition is causing [Describe the medical problems caused by the malocclusion, e.g., difficulty chewing, speech impediments, jaw pain, temporomandibular joint (TMJ) disorder, increased risk of dental trauma, breathing difficulties].
I have attached the following documentation to support this request:
* A detailed evaluation and treatment plan from [Orthodontist’s Name], DDS, including X-rays and photographs.
* A letter from [Orthodontist’s Name], DDS, explaining the medical necessity of the proposed orthodontic treatment and its potential benefits.
* [Include any other relevant medical records or referrals from other doctors].
Based on the information provided, the orthodontic treatment is medically necessary to alleviate [Patient Name]’s medical problems and improve [his/her] overall health.
I urge you to approve this request for pre-authorization. Please contact me at [Your Phone Number] or [Your Email Address] if you require any additional information.
Thank you for your time and consideration.
Sincerely,
[Your Name]
How to Write Letter To Unitedhealthcare Requesting Medically Necessary Orthodontia
1. Crafting a Compelling Subject Line
The subject line is your first (and perhaps only) chance to seize their attention. Don’t squander it!
- Be direct: “Prior Authorization Request for Medically Necessary Orthodontia – [Patient Name]”
- Include the policy number: “Prior Authorization – Policy #[Policy Number] – [Patient Name] Orthodontia”
- Evoke urgency subtly: “Urgent: Orthodontia Prior Authorization Request – [Patient Name]”
2. The Salutation: Setting the Stage for Professionalism
Address the recipient with respect and decorum; this isn’t a casual email.
- If you know the specific claims adjuster, use their name: “Dear Mr./Ms. [Adjuster’s Last Name],”
- If the adjuster’s name is unknown, opt for a formal acknowledgment: “Dear UnitedHealthcare Prior Authorization Department,”
- Avoid overly familiar greetings like “Hi” or “Hello.” Maintain professional distance.
3. Articulating the Medical Necessity: The Core Argument
This is where you substantiate your claim. Provide a succinct yet persuasive narrative of the patient’s condition.
- Begin by stating the patient’s diagnosis: “This letter pertains to [Patient Name], diagnosed with [Specific Malocclusion, e.g., Class II skeletal malocclusion, severe overjet].”
- Elaborate on the functional impairment: “This condition precipitates significant functional impediments, including [difficulty chewing, speech impediments, temporomandibular joint dysfunction].”
- Emphasize the ramifications of inaction: “Without timely orthodontic intervention, [Patient Name] faces the prospect of [worsening TMJ, increased risk of dental trauma, chronic pain].”
4. Citing Supporting Documentation: Fortifying Your Position
Evidence is paramount. Meticulously document all supporting materials to bolster your request.
- List all enclosed documents: “Enclosed, please find the following supporting documentation:”
- Specify each item: “[Orthodontist’s Comprehensive Evaluation], [Cephalometric Radiographs], [Photographs], [Referring Physician’s Letter of Recommendation]”
- Provide brief descriptions: “The Orthodontist’s Comprehensive Evaluation delineates the severity of the malocclusion and the proposed treatment plan.”
5. Delineating the Proposed Treatment Plan: Clarity is Key
UnitedHealthcare needs to understand the specifics of the proposed orthodontic treatment.
- Summarize the treatment plan: “The proposed treatment entails [Comprehensive orthodontic therapy with fixed appliances, orthognathic surgery in conjunction with orthodontics].”
- Specify the duration: “The estimated treatment duration is [Number] months.”
- Highlight the intended outcomes: “The anticipated outcomes include [Improved occlusion, enhanced masticatory function, alleviation of TMJ symptoms].”
6. Underscoring Policy Compliance: Demonstrate Diligence
Show that you are well-versed in UnitedHealthcare’s policies regarding orthodontic coverage.
- Reference the specific policy: “This request aligns with UnitedHealthcare’s policy regarding medically necessary orthodontia, specifically section [Policy Section Number].”
- Quote relevant excerpts: “As per policy [Policy Section Number], orthodontia is covered when it is ‘deemed necessary to correct a severe congenital or acquired malocclusion that significantly impairs function.'”
- Reiterate how the patient meets the criteria: “As detailed in the enclosed documentation, [Patient Name]’s condition unequivocally meets these criteria.”
7. The Closing: A Final Flourish of Professionalism
End the letter with a courteous and proactive closing.
- Express gratitude: “Thank you for your time and meticulous consideration of this crucial request.”
- Offer further assistance: “Please do not hesitate to contact me should you require any further information or clarification.”
- Use a formal closing: “Sincerely,” or “Respectfully,”
- Include your contact information: [Your Name], [Your Phone Number], [Your Email Address]
Frequently Asked Questions: Sample Letter for UnitedHealthcare Orthodontia Pre-Authorization
This section addresses common questions regarding sample letters used to request pre-authorization from UnitedHealthcare for medically necessary orthodontia.
The following information is intended for informational purposes and should not be considered legal or medical advice.
What constitutes “medically necessary” orthodontia?
Medically necessary orthodontia generally refers to treatment required to correct a severe malocclusion that significantly impairs function, such as chewing, speech, or jaw joint function, and where other medical or surgical interventions may be required.
What information should be included in a sample letter?
A sample letter should include the patient’s name, date of birth, UnitedHealthcare insurance information (policy number, group number), a clear statement of medical necessity, a detailed description of the malocclusion, supporting documentation from the orthodontist (e.g., X-rays, photographs, clinical notes), and the specific treatment plan being recommended.
Where can I find a sample letter template?
While specific templates vary, you can often find examples online by searching for “sample letter for orthodontia pre-authorization UnitedHealthcare.” It is recommended to consult with your orthodontist’s office, as they may have pre-approved templates or suggestions.
What supporting documentation is required?
Supporting documentation typically includes a comprehensive orthodontic evaluation, cephalometric X-rays, panoramic X-rays, photographs of the patient’s teeth and face, and a detailed explanation of the diagnosis and proposed treatment plan. A narrative explaining the functional impairment is also critical.
What if my request is denied?
If your request is denied, you have the right to appeal the decision. The denial letter from UnitedHealthcare will outline the appeals process. You may need to provide additional documentation or a letter from your primary care physician supporting the medical necessity of the treatment.