Letter of Medical Necessity - HealthPartners 2025

1. Click ‘Get Form’ to open the Letter of Medical Necessity in the editor.
2. Begin by filling in the Employee Information section. Enter the Patient Name, Employer Name, Employee Name, and Employee SSN clearly.
3. In the Diagnosis field, ensure that your medical practitioner provides a specific diagnosis. Avoid vague terms; specificity is key for approval.
4. Next, input the CPT Code(s) relevant to the treatment being requested. This code helps identify the specific services provided.
5. Detail the Specific Recommended Treatment. Your provider should describe this thoroughly, including any necessary programs or therapies.
6. Fill in the Start Date and End Date of treatment accurately to avoid delays in processing your claim.
7. Ensure your medical practitioner signs and dates the form, certifying that the treatment is medically necessary and not for cosmetic purposes.
8. Finally, submit the completed form via mail or fax as indicated at the bottom of the document.

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