Sample Ancillary Medical Services Development Letter
Claimant: (or Auth Rep/Provider) Case ID:
Street Address Accepted Condition(s):
City, State, Zip
Dear [Enter Claimant or Auth Rep]:
I am writing to you concerning your benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). We have received a request for authorization for the [Enter type of ancillary medical service requested]. In order to properly evaluate and respond to this request, we need additional information from you.
Please provide our office with the following information:
(Request only that information that is necessary to process the claim. Feel free to modify the following, if necessary.)
o Prescription from your treating physician (should include diagnosis code(s) for the condition for which the item(s) is being prescribed).
o Letter of Medical Necessity or other medical documentation (describe the general information a LMN is to provide.
o Claimant information such as name, case file number, date of birth, and telephone number.
o Provider or vendor information such as name, provider address, ACS provider number, Tax ID number, national provider identification number, telephone number, and fax number.
o Treating physician contact information such as name, address, telephone number, and fax number.
o DME information such as diagnosis code, HCPCS/CPT, modifier, quantity, purchase price, rental price, total cost, begin date, end date, and duration of use.
You have 30 calendar days to provide the additional information. Your lack of response or submission of insufficient evidence will result in a denial of the request.
In the interest of expediting the approval of your request for [Enter type of Ancillary Medical Service], please fax the requested information to the DEEOIC Bill Processing Agent at (800) 882-6147, within 30 days, or contact me if you have questions regarding this request.
Thank you for your assistance.
[Enter POC CE Name and Signature]
[Enter POC CE Telephone and Fax Numbers]
cc: [Enter as appropriate]