Sample Email/ Letter Of Medical Necessity (Parent / Guardian)

Date: ___________

To: TriCare Utilization Management Department

Re: Request for Out-of-Network Pediatric Psychiatry Services (Medical Necessity)

To whom it may concern,

I am the parent or legal guardian of a TriCare-insured child who requires ongoing pediatric psychiatric care.

My child has a documented medical need for psychiatric evaluation and/or medication management. After extensive efforts, we have been unable to locate an in-network child and adolescent psychiatry provider in our geographic area who can provide timely and appropriate care. In-network options have excessive wait times, are not accepting new pediatric patients, or are unavailable within a reasonable distance.

Due to this lack of access, my child is currently receiving care through MindWeal Health, a pediatric psychiatry practice that specializes in the evaluation and treatment of children and adolescents. Maintaining continuity of care is medically necessary for my child’s emotional health, stability, and overall well-being.

Disruption or delay of psychiatric care could result in worsening symptoms, academic difficulties, emotional distress, and increased risk of crisis-level care. For these reasons, continued access to pediatric psychiatric services is essential.

I respectfully request that TriCare approve MindWeal Health as an Out-of-Network provider for my child so that medically necessary psychiatric care may continue without interruption.

Thank you for your time and consideration.

Sincerely,

Parent/Guardian Name: __________________________
Child’s Name: _________________________________
Child’s Date of Birth: __________________________
TriCare Member ID: _____________________________
Phone or Email (optional): _______________________