February 5, 2012

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Insurance Reimbursement
Letter

When a child with special medical conditions requires a specialized car safety seat or safety restraint, you will need to write a letter to your insurance carrier detailing justification of financial reimbursement.

It is suggested that this letter have a greater focus on the child's positioning needs and medical necessity than on just the need for a car seat. Reminder: The Ohio car seat law only covers children until they reach 8 years of age or 4'9", therefore by law a child over 4'9" or 8 years of age in need of a special positioning car seat is not required by Ohio law to be in a car seat. For this reason, stress the medical and safety concerns for this child.

The Letter of Medical Necessity should come from health care practitioners involved with the care of this child such as doctors and therapists, and could include those individuals involved with the school Individual Education Plan (IEP), transportation specialists, etc.

In this letter, describe the child and his/her medical conditions. Be specific so that a third party payer understands the child's needs and how this special car seat will assist in this child's daily functioning and what will be accomplished by the use of this special car seat. For example, the child may need the seat to travel to medical appointments and school and may have positioning or other needs that a conventional car seat doesn't accommodate. Have all disciplines sign this letter.

This letter should include the following information:

• Date
• Child's name
• Age and date of birth
• Height
• Weight
• Primary/secondary insurance information
• Medical diagnosis
• Current level of functioning
• Medical history (including the child's physical/medical conditions that will be affected by the use of the recommended car seat, their range of motion, muscle tone, posture description, how much assistance is needed, etc.)
• How the child is currently transported in a vehicle
• Recommended car seat (name, model and a description of the special car seat including features and cost) and why this specific car seat was chosen
• What are the child's travel destinations/needs
• The expected outcomes from using this car seat
• Other medical equipment being used by this child
• Child's current therapy program including short-term and long-term goals
• Signatures with contact information (address and telephone numbers)
• Include a copy of medical evaluations highlighting need and a doctor's prescription

NOTE: COLUMBIA 2000 and 2500 Positioning Seats: Columbia Medical Manufacturing has an electronic form letter to complete for their products on their Web site: www.columbiamedical.com.

Sample letter:

(ON LETTER HEAD)

February 18, 2004

RE: Request for Equipment:

Patient Name: ________________
D.O.B.: _____________________
Date of Adaptive Equipment Evaluation: ________
Therapist: ______________

To Whom It May Concern: (Child's name) is a 4 year 5 month old female with a diagnosis of cerebral palsy. She was referred to occupational therapy and physical therapy by (physician's name) for impaired fine and gross motor skills.

(Child's name) is currently being seen in both occupational and physical therapy, with treatment focusing on improving gross motor abilities, improving fine motor abilities, improving cognitive-perceptual abilities, increasing strength, improving coordination and improving mobility. She is currently in need of a crash tested child safety seat for safe car transportation. A Snug Seat Gorilla Car Seat is recommended as it is a federally approved, crash tested child safety seat that has the ability to grow with (child's name) up to 105 pounds. Currently Ohio's state law requires that (child's name) be in a federally approved, crash tested child safety seat for car transportation. (Child's name) has outgrown the car seats that can be purchased at retail stores due to her increased height and need for additional cervical and trunk support due to her neurological condition.

This equipment is necessary for (child's name) in order to:

• Improve safety during transportation due to her decreased balance in sitting and poor muscle control
• Maintain a safe upright sitting position during travel and prevent deformity producing positions
• Reduce the risk of suffering an injury which could further complicate and decrease her medical status

Thank you for considering (child's name)'s needs. Your prompt response regarding this request would be greatly appreciated. If you have any questions or concerns, please contact me at _________.

Sincerely...