[Your Full Name]

[Your Address]

[Your Telephone Number]

[Date]

[Address]

Re: [Name of Beneficiary], Member # [Member ID Number] Claim # [Claim Number]

To Whom It May Concern:

I am writing to request pre-approval for [service] by [name of provider]. 

I have reviewed my policy and believe that [name of health care plan] is required to cover this service. [Service] is evidence-based and is medically necessary in order to ensure that [Beneficiary] can communicate effectively. 

I am attaching a letter from [Beneficiary]’s [type of treatment provider], [name], explaining that this intervention is evidence-based and medically necessary due to [describe specific needs of the beneficiary that will be addressed by the service]. The intervention will address these needs by [describe what is involved in the intervention].

[For a continuing service, add:] As recommended by [treatment provider], I am requesting pre-approval for x hours/visits per day/week/month.  

[Add more detailed information if possible. If you are including other documents such as prior assessments or other information, include a list of what you are sending here.] 

If you need additional information, I can be reached at [telephone number and/or e-mail address]. 

Sincerely,

[Signature]

[Typed Name]