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SAMPLE: Letter of Medical Necessity of out-of-network provider for TriCare in Metro East STL

SAMPLE GENERAL LETTER OF MEDICAL NECESSITY

(For PCPs to submit to TriCare on behalf of their patient population and region)

[PCP Letterhead]

Date: ___________

To: TriCare Utilization Management Department

Re: Medical Necessity for Out-of-Network Pediatric Psychiatry Services in Metro East St. Louis & Southern Illinois


Dear Medical Director,

I am writing to formally document the medical necessity for continued access to Out-of-Network Pediatric Psychiatry services with MindWeal Health for TriCare-insured children and adolescents in the Metro East St. Louis and Southern Illinois region.

Severe Shortage of In-Network Child & Adolescent Psychiatrists

At this time, there is a critical and well-documented shortage of in-network Child & Adolescent Psychiatry providers in this geographic area, resulting in:

  • Excessive wait times (often several months)
  • Limited or no availability for new pediatric patients
  • Delays in diagnostic clarification and medication initiation
  • Increased emergency department utilization
  • Escalation of psychiatric symptoms, school impairment, and family crisis

For many TriCare-insured families in this region, there are effectively no realistic in-network options for timely pediatric psychiatric care.

Medical Necessity of MindWeal Health

MindWeal Health provides specialized child and adolescent psychiatric evaluations and ongoing medication management for youth ages 4–18. These services are medically necessary for conditions including, but not limited to:

  • ADHD
  • Anxiety disorders
  • Mood disorders
  • Trauma-related disorders
  • Autism-related psychiatric conditions
  • Behavioral dysregulation requiring psychiatric medication oversight

These services are essential medical treatment, not elective care.

Need for Out-of-Network Authorization

Due to the lack of available in-network child psychiatry providers, it is clinically necessary for TriCare to approve MindWeal Health as an Out-of-Network provider in order to ensure:

  • Timely psychiatric access
  • Continuity of care
  • Prevention of unnecessary emergency department visits and hospitalizations
  • Reduction of long-term psychiatric morbidity

Prevention of Service Disruption

Without Out-of-Network authorization for MindWeal Health, TriCare-insured pediatric patients in this region—including those from my practice—will face unavoidable service disruptions, as there are no viable in-network alternatives with reasonable access.

This disruption poses a direct risk to patient safety, academic functioning, family stability, and long-term mental health outcomes.


Formal Request

Based on the above, I strongly support and formally request that TriCare:

  • Approve MindWeal Health as an Out-of-Network Pediatric Psychiatry Provider
  • Authorize coverage for psychiatric evaluations and ongoing medication management