Letter of Medical Necessity - Healthcare Services



Letter of Medical Necessity

Please print or type information below and complete form in its entirety

The following MHCP member has requested to be seen at       for medical services. They have requested MNet to authorize transportation to this facility; which is       miles from their home. MNet is required to provide transportation to the closest medical provider able to provide medical services. Please provide an explanation as to why medical services cannot be provided at a closer medical facility.

Patient Name:       DOB:       MA #:      

1. Diagnosis for which you are treating member: _____________________________________________

_____________________________________________________________________________________

2. Have you referred the patient to be seen by a specialist? Yes No

o Physician/Specialist name _________________________________________________

3. Can the patient receive treatment at a closer medical facility? Yes No

o If Yes, please list: _______________________________________________________________

o If No, complete section 4 below:

4. Please indicate treatment/services, and why they cannot be preformed at medical facility closer to the patient’s home:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

5. Anticipated duration of treatment: ______________________________________________________

X_____________________________________ ________________ _________________________ Provider Signature Date Contact #

_________________________________ ________________ __________________________

Provider Name (printed) Provider License # Facility Name

Medical Transportation Management, Inc. (MTM) arranges non-emergency transportation services to medically necessary appointments for patients who qualify under Minnesota Healthcare Program (MHCP). Minnesota Non Emergency Transportation (MNet) operated by MTM, is required by the Department of Human Services (DHS) to verify MHCP patients receive medical services from the closest and most appropriate provider. MNet has a Business Associates Agreement with the State of Minnesota and therefore is covered under HIPAA rules and regulations.

Upon completion, please fax this form with cover sheet to:

MNet’s Care Management Department

Fax: 651-203-1262

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