[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-265961-105":3,"doc-detail-265961-en":73,"detail-sidebar-cat-0-en-105":89},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":66,"head_meta":68,"extra_data":70,"updated_unix":72},105,"en","letter-of-medical-necessity-instructions-and-reimbursement-requirements","Letter of Medical Necessity - Instructions and Reimbursement Requirements","","Reimbursement eligibility for healthcare products and services requiring a Medical Practitioner’s authorization under a Flexible Spending Account (FSA), Health Reimbursement Arrangement (HRA), or other TASC benefit account. The participant completes Section I, then provides the form to the attending Medical Practitioner to complete Section II following state pharmacy and prescription laws. Completed forms must be submitted with each reimbursement request, with effectiveness for 12 months or until the benefit plan year ends; new forms are required for each plan year or treatment plan change.",{"@graph":14,"@context":65},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/letter-of-medical-necessity-instructions-and-reimbursement-requirements/265961/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/letter-of-medical-necessity-instructions-and-reimbursement-requirements/265961.png","ImageObject",300,407,{"name":42,"@type":43},"Eliana","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-14",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59],{"name":60,"@type":61,"acceptedAnswer":62},"How long is the Letter of Medical Necessity effective?","Question",{"text":63,"@type":64},"It is effective for 12 months from the Medical Practitioner’s signed date or until the end of the benefit plan year in which it was submitted. A new form is required each plan year or whenever the treatment plan changes.","Answer","https://schema.org",{"og:url":32,"og:type":67,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":69,"canonical":32},"index,follow",{"doc_id":71,"site_id":7},265961,1789402831,{"code":4,"msg":74,"data":75},"success",{"doc_id":71,"user_id":76,"nickname":42,"user_avatar":77,"doc_module":4,"category_id":78,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":79,"file_id":80,"file_url":81,"file_type":82,"file_size":83,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":84,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":85,"faqs":86,"seo_title":87,"seo_description":12,"update_tm":72,"read_time":88},4398048949847,"https://ap-avatar.wpscdn.com/avatar/400002536579ef2da7f?_k=1778318612642679267",7,"Use this form to be reimbursed for healthcare products and services that require authorization from a Medical Practitioner to be considered eligible for reimbursement from a Flexible Spending Account (FSA), Health Reimbursement Arrangement (HRA) or other TASC benefit account.  \nINSTRUCTIONS  \n• Complete the form on the following page.  \n1. Complete Section I (including your signature and the date) prior to visiting your Medical Practitioner.  \n2. Bring this form with you to your next medical appointment and request that the attending Medical Practitioner complete Section II. Instruct them to follow the specific pharmacy / prescription laws in their respective state when completing Section II.  \n• You must submit a copy of this completed form to TASC with each request for reimbursement (if submitting online, include a copy with your receipts). Any Letter of Medical Necessity received without a request for reimbursement will not be processed.  \n• The Letter of Medical Necessity will be considered effective for 12 months from the date signed by the Medical Practitioner, or until the end of the benefit plan year in which it was submitted. A new form must be submitted each plan year in which you request reimbursement, or any time the treatment plan changes.  \n• Both sections of the form must be completed in full. Incomplete forms may result in delay in processing or denial of your request for reimbursement.  \nDEFINITIONS (for the purposes of this form)  \n• “Letter of Medical Necessity” refers to any order for healthcare products or services signed by a licensed Medical Practitioner granted prescriptive authority by the laws of the state. It contains the name and quantity of the medicine/product/service prescribed, directions for use, and treatment duration.  \n• “Medical Practitioner” generally includes the following licensed health professionals: physician (MD/DO), physician assistant, nurse practitioner, dentist, optometrist, and podiatrist.  \nProducts and services that require a Letter of Medical Necessity or other Medical Practitioner authorization to show the expense is to treat a medical condition include* the following:  \n• Air purifier  \n• Automobile modifications  \n• Ear plugs  \n• Exercise equipment  \n• Gym or health club memberships  \n• Massage therapy  \n• Nutritionist’s professional fees  \n• Orthopedic shoes (excess cost only)  \n• Support hose (below 30 mmHg)  \n• Varicose vein treatment  \n• Vitamins and supplements  \n• Waterpik™  \n• Whirlpool® or spa  \n• Wigs  \n* Not a complete list.  \n\n| Include this completed form with your request for reimbursement online, or submit via fax or mail: | Fax | Mail |\n| --- | --- | --- |\n|  | 608-245-3623 | PO Box 7308\u003Cbr>Madison, WI 53704-7308 |\n\nSECTION I – PARTICIPANT AUTHORIZATION  \n\n| Participant Name: |  | Employer Name: |  |\n| --- | --- | --- | --- |\n| Participant TASC ID: |  | Email Address: |  |\n| The statements in this document are complete and true, to the bestof my knowledge and belief. I understand that theIRS regulates my benefit account(s) and that the guidelines are implemented asa means of ensuring compliance with reimbursable expenses and thatTASC reserves the right to verify the eligibility of the expenses in accordance with IRS regulations. I further understand that it is my responsibility to comply withthese guidelines and to avoid submittingduplicate or ineligible requests.\u003Cbr>Participant’s Signature Date |  |  |  |\n\nSECTION II – TREATMENT INFORMATION  \nTo be completed by Medical Practitioner. All fields are required.  \n\n| Patient Name: |  |\n| --- | --- |\n| Relationship to Participant: |  |\n\n\n| Prescribed Treatment Product / Services | Reason for Treatment / Medical Condition | Instructions / Restrictions (if applicable) | Date of\u003Cbr>Diagnosis / Onset | Duration /\u003Cbr>No. of Treatments |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |","cbCairb1zRK9Og1r","https://ap.wps.com/l/cbCairb1zRK9Og1r","pdf",196102,"English","# Instructions\n## Section I – Participant Authorization\n## Section II – Treatment Information","[{\"question\":\"How long is the Letter of Medical Necessity effective?\",\"answer\":\"It is effective for 12 months from the Medical Practitioner’s signed date or until the end of the benefit plan year in which it was submitted. A new form is required each plan year or whenever the treatment plan changes.\"}]","Letter of Medical Necessity - Instructions and Reimbursement Requirements | PDF",5,{"code":4,"msg":74,"data":90},[91,95,99,103,107,112,115,120,125,128,132],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":92,"show_sort_weight":93,"slug":94},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},"Exam",70,"exam",{"id":88,"doc_module":4,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},"Comic",60,"comic",{"id":108,"doc_module":4,"doc_module_name":25,"category_name":109,"show_sort_weight":110,"slug":111},6,"Technology",50,"technology",{"id":78,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":113,"slug":114},40,"healthcare",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},8,"Research & Report",30,"research-report",{"id":121,"doc_module":4,"doc_module_name":25,"category_name":122,"show_sort_weight":123,"slug":124},9,"Religion & Spirituality",20,"religion-spirituality",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":126,"show_sort_weight":123,"slug":127},"World Cup","world-cup",{"id":129,"doc_module":4,"doc_module_name":25,"category_name":130,"show_sort_weight":129,"slug":131},10,"Lifestyle","lifestyle",{"id":133,"doc_module":4,"doc_module_name":25,"category_name":134,"show_sort_weight":88,"slug":135},19,"General","general"]