Finally, Help Through the Funding Maze. . .
Illinois Assistive Technology Program Funding Manual

A Recipe for Success
Justification Letters To Insurance Companies for Assistive Technology

To get a health insurance company to pay for assistive technology (AT), a justification letter must accompany all requests. Knowing how to write it makes all the difference. It’s like building a bridge from one shore to another. If an insurance company, on its side, cannot see the connection between its policy, it will likely say no. The justification shows the insurance company the insured’s side of the river, her need and the entitlement promised in the policy. The justification is the bridge between the two. Use this guide to help write justifications to an insurance company.

The Justification Letter

Teams often decide if a likely user actually needs AT. The justification can come from the entire team jointly, or from each team member individually. Typically, the assessor with expertise in the specific area of technology writes the justification.

Members of assessment teams can include: Speech Language Pathologists, Occupational Therapists, Physical Therapists, Rehabilitation Specialists, Physicians, and/or other professionals who can help justify need for the device.

Justification Letter Recipe

• Use official letterhead
• Date
• Name and address of funding source
• Use headings for each section. The outline below offers some heading suggestions. Make the report easy to read and easy to follow.
• Use a specific salutation - Not "To whom it may concern". More like, “To the Claims Division, Blue Cross/Blue Shield of Illinois”.

Start with a Summary

Put it right up front. Then the reader does not have to look for it. Some people like to write this part last, but always put it first.

• Insured’s name
• Policy number
• Justification author
• Findings
• Recommendations
• Cost

Introduction

• Identify the person.
• Team members and credentials - do not forget the individual and the caregivers.
• Diagnosis
• Functional Prognosis

Evaluation

• Explain what devices the team considered with statements of why the devices worked, or didn’t work, for the person.
• Be sure to rule out lower cost alternatives, showing why they are inappropriate for the user.
• Explain the insured’s medical functioning skills without the equipment and how they will be improved with AT.
• Name of the AT device being requested.

Device Specifications

• Individual descriptions for each component of AT being requested with justification statements as it pertains to the individual.
• Terminology that is consistent with the funding agency from which financial assistance is being sought.
• Cost
• Other information, if needed.

Consequences

• Statement describing some possible consequences for the individual needing AT if the device is not funded - this will vary with each type of funding source.

Ending

• Statement thanking the agency for considering the request.
• Closing - Sincerely, etc.
• Author’s contact information. Signature
• Complete name and all credentials, unabbreviated, of the practitioner requesting the funding.

Additional Information to Accompany Justification

When sending a request to a funding agency you may want to include some of, or all of, the following additional information:

• Physician prescription.
• Letter of medical necessity from the physician.
• Letters of medical necessity from other professionals involved with the case.
• Specifications of the equipment including cost and photograph or catalog picture.
• Evaluator’s Professional Vita

Letters from Individuals or Parents and Teachers/Case Managers/Counselors

A letter from the potential user or her parents (if the user is a child), accompanying the justification, can be valuable . Letters from the individual's teacher, case manager or counselor can also help support the justification. It’s important that these letters talk only about the medical need and benefits of the device. Below are key points these letters should contain.

Individual's or Parent's letter:

• Medical history and diagnosis.
• Length of time you have provided/received services.
• Comment on the device’s effectiveness to meet medical needs . (As a parent, comment if you have seen the insured use it.)
• Provide comments about the insured’s ability to physically access the device.

Teacher's, Case Manager's, or Counselor's Letter:

• Medical history and diagnosis.
• Length of time you have provided services.
• Comment on the device’s effectiveness if you have seen the insured use it.
• Provide comments about the insured’s ability to physically access the device.

Don't forget the extras

Assessment teams frequently focus only on the device at hand. There is much more to consider for the insured to effectively use a device.

Think about how the insured will use the equipment and what extras are necessary to successfully use the device, and add them to the request. Examples might include, carrying cases, special seating, mounting devices/brackets, and/or batteries.

• User training
• Caregiver training
• Regular maintenance
• Repairs
• Replacement parts.

This document was adapted from the fine piece of work by Luebben, A.J. (1992). Documentation for assistive technology. In J.D. Acquaviva (ed.), Effective Documentation for Occupational Therapy, (pp.123-140). Rockville, MD. The American Occupational Therapy Association, Inc., and The Road to Funding, Prentke Romich Company, 1022 Heyl Rd., Wooster, OH 44691

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