Letter of medical necessity for transportation: a fill-in letter for wheelchair, stretcher, and escort needs

What a payer needs the letter to say

The letter has to say what the patient cannot do and why a cheaper way of traveling would be unsafe, in a clinician’s own words. A diagnosis alone does not do it. Medicaid pays for the least costly mode that is appropriate for the beneficiary’s physical and emotional condition (CMS’s 2023 transportation guide, SMD 23-006). Medicare covers an ambulance only when the patient’s condition is such that “other means of transportation are contraindicated” (42 CFR 410.40(e)). The medical necessity form entry shows the state forms that ask for the same thing, and this page gives the letter for the cases those forms do not reach.

Payers reject statements that give only a diagnosis, leave out why the trips are needed or how often, or give no length of time. Medi-Cal’s prescription is the closest thing to a model for a letter: it asks for the purpose of the trip, how often the patient has to go or the dates covered, and the condition that makes normal public or private transportation inadvisable, plus a treatment plan when the rides are ongoing. The same entry shows what New York and Ohio reject.

A Medicaid letter supports a decision that is not the clinician’s. Federal rules describe covered transportation as expenses “determined to be necessary by the agency” (42 CFR 440.170(a)), and they include the cost of an attendant “if necessary”. The letter gives the agency or broker what it needs to decide.

The template

Copy the letter below onto the clinician’s letterhead. The clinician fills in the brackets from the patient’s chart. The transportation company can send this page along as a model, but the clinician writes and signs the letter.

[Date]

To: [Program, broker, or health plan name and address, or “To whom it may concern”]

Re: [Patient name], date of birth [date], member ID [number]

I am [patient name]‘s [physician / nurse practitioner / physician assistant / other], and I have treated [him / her / them] since [date]. This letter explains why [he / she / they] [needs / need] [a wheelchair van / a stretcher van / an attendant / door-through-door help] to travel to [dialysis / chemotherapy / therapy / the clinic].

Condition and what the patient cannot do. [Patient name] has [diagnosis]. Because of it, [he / she / they] cannot [walk more than __ feet / stand without help / transfer without a lift or two people / sit upright for more than __ minutes / travel without monitoring]. [Add what you observe in the office: for example, uses a power wheelchair and cannot bear weight.]

Service needed.

• ☐ Wheelchair van with a lift or ramp, chair secured in the vehicle
• ☐ Stretcher van
• ☐ Non-emergency ambulance
• ☐ An attendant or escort who can [describe what the person must be able to do]
• ☐ Help beyond the curb: door-to-door ☐ door-through-door ☐

Why a lower level is unsafe. A car, taxi, or bus is unsafe because [reason]. [If a stretcher or ambulance is requested: A wheelchair van is not enough because [reason].]

Trips covered. The purpose is [treatment or service], at [facility or provider], about [number] times a [week / month], from [start date].

Length of need. The need runs from [start date] to [end date] [or: is ongoing]. I will review it by [date], or sooner if [his / her / their] condition changes. A new letter will follow any change.

Attendant (if requested). [Patient name] cannot travel alone because [reason]. The attendant must be able to [describe].

I am available at [phone] to answer questions from the program or the transportation provider.

[Signature]

[Printed name], [title] License number [number] | NPI [number] | Phone [number] Date signed: [date]

Check it before it goes out

Four checks keep a letter from being rejected or questioned.

1. Describe what the patient does, not only the diagnosis. “Needs a stretcher” says what is wanted, not why. A line such as “cannot sit upright for more than ten minutes and cannot be moved without a two-person lift” (an example, not a standard) says why.
2. Write each patient’s letter from that patient’s chart. New York’s Form-2015 policy says the Department is alerted when one medical provider submits forms for several enrollees with a similar justification, and the provider may be asked to meet with the transportation manager and resubmit corrected forms.
3. Say only what the chart supports, and keep the transportation company out of the signature block. Ohio treats a false certification as Medicaid fraud, with the example of certifying a wheelchair van for a person who has no mobility device and never uses one. It also bars anyone tied to the transportation provider from certifying its service.
4. Date it, give an end, and redo it when things change. Ohio counts its 90-day and one-year certification periods from the earlier of the signature date or the first date of service, so the signature date matters. A new letter follows any change in the patient’s condition or level of service.

When a state form must be used instead

Where a Medicaid program has its own form, the form is what the broker accepts and the letter only adds detail. The medical necessity form entry compares the New York, Illinois, and Ohio forms side by side, including who signs and how long each lasts, and explains how California’s Medi-Cal fee-for-service works from a prescription instead.

Two programs show the other ways a letter can fit:

• Georgia. The NEMT manual has the broker secure a Medical Necessity Certification or a Letter of Medical Necessity for stretcher transport, and says the broker should have it in place before the third scheduled stretcher ride for the member to keep riding at that level.
• Missouri. A rider confined to bed needs the Stretcher Assessment Form, which comes from the broker.

The guide to level of service downgrades shows what happens to a trip when the paperwork does not hold the level.

Where a letter helps outside Medicaid, and where it does not

A letter helps with an appeal to a private health plan, a Medicare ambulance claim, and a private-pay file. It adds little to an HSA or FSA claim for an ordinary ride, and it does nothing for ADA paratransit eligibility.

A denied claim from an employer health plan. Under the federal claims rule for employee benefit plans, a group health plan must give at least 180 days to appeal a denial, let the claimant submit written comments, documents, and other information, and consider all of it whether or not it was before the first reviewer. When the denial rests on medical judgment, the plan must consult a health care professional with the right training. A letter that states the functional facts is the kind of document that review takes into account. The private insurance guide explains which plans cover rides at all.

A Medicare ambulance claim. A physician certification statement does not by itself show that ground ambulance was necessary. Medicare wants the statement and other medical record documentation to give detailed explanations of why the patient needs an ambulance. A letter’s facts have to agree with the chart, because the rule asks that the explanation fit the patient’s current condition. The ambulance versus NEMT guide covers the rest of the paperwork.

Private-pay and facility rides. No state form applies, so a letter in the rider’s file is the record of why a stretcher or a two-person crew was booked and priced.

HSA and FSA claims. A ride to treatment needs a receipt, not a letter. The HSA and FSA entry lists what the receipt should show. A letter is worth adding when the claim includes an attendant’s fare.

ADA paratransit. A letter does not qualify anyone. The transit agency’s process decides, in writing, and a missing decision 21 days after a complete application means the applicant is treated as eligible under 49 CFR 37.125(c).

Matching the rider’s level in HealthRide

When a letter covers months of dialysis rides, set the recurring trip up once and HealthRide keeps it going, with wheelchair, stretcher, and oxygen needs matched to a vehicle that can carry them. Dispatch assigns each trip in one motion on the dispatch board, and the fleet page explains how vehicle capacity is recorded.