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Submission provides the information required to process a claim.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must the provider include on the LMN?",{"text":68,"@type":64},"The provider must state the recipient’s specific diagnosis, the specific treatment needed, the length of treatment, and how the treatment will alleviate the medical condition. Diagnosis/ICD code and related treatment fields are required.",{"name":70,"@type":61,"acceptedAnswer":71},"How often should the LMN be submitted and what are the limits?",{"text":72,"@type":64},"Submit the LMN once per plan year if it is accepted. A new LMN must be provided each year and cannot be approved indefinitely, and submitting does not guarantee reimbursement.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},276693,1789494850,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,114,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},17,"Forms",40,"forms",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":116,"slug":117},18,30,"letters",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":115,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":4},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","Letter of Medical Necessity  \nUnder Internal Revenue Service (IRS) rules, some health care services and products are only eligible for reimbursement from health flexible spending arrangements (health FSAs) or health reimbursement arrangements (HRAs) when your doctor or other licensed health care provider certifies that they are medically necessary. Your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific treatment needed, the length of treatment, and how this treatment will alleviate your medical condition. Please use this form letter to assist you and your health care provider in providing the information we need in order to process your claim. By submitting this LMN you certify that the expenses you are claiming are a direct result of the medical condition described below, and you would not incur the expenses you are claiming if you were not treating this medical condition.  \nThe LMN form only needs to be submitted once per plan year, provided the submitted LMN is accepted. You must submit a new LMN each year—they cannot be approved indefinitely. Submitting this form does not guarantee that the expense will be reimbursed.  \n* Name of person receiving treatment  \n* Date treatment was recommended  \n* Employee Name  \n* Member ID (which may be your SSN)  \n* Provider Name  \n* Diagnosis/ICD code  \n* Please note this information is required.  \nEmail Address  \n* Employer  \n*CPTCode (if any)  \n\n| *Specific Medical Condition | * Recommended Treatment | * How Treatment Will Aid Condition |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\n*  \n*  \n*  \n*  \nProvider Signature  \nProvider Name  \nProvider Address  \nProvider License Number  \n*Provider Telephone   \nOnce the form has been completed and signed, please return one of the following ways: Mail: CPI 6421 Perkins Rd, Bldg A, Suite 2A, Baton Rouge, La 70808  \nEmail: [cpisupport@mycpiteam.com](cpisupport@mycpiteam.com) Fax: 225-706-0280  \nCPI | 6421 Perkins Rd Bldg A Suite 2A | Baton Rouge, La 70808 Phone: 866-241-0237 | Fax: 225-706-0280 [cpisupport@mycpiteam.com](cpisupport@mycpiteam.com)","cbCaiceBdw8gJM1x","https://ap.wps.com/l/cbCaiceBdw8gJM1x","pdf",710307,"English","# LMN Purpose and IRS Requirements\n## Provider Certification Details\n## Submission Timing and Reimbursement Notes\n## Required Information Fields\n## Medical Condition, Treatment, and Outcome Table\n## Provider Signature and Contact Details\n## How to Submit (Mail/Email/Fax)","[{\"question\":\"What purpose does the Letter of Medical Necessity (LMN) serve?\",\"answer\":\"The LMN helps document that requested services or products are medically necessary for reimbursement under health FSA or HRA arrangements. Submission provides the information required to process a claim.\"},{\"question\":\"What information must the provider include on the LMN?\",\"answer\":\"The provider must state the recipient’s specific diagnosis, the specific treatment needed, the length of treatment, and how the treatment will alleviate the medical condition. Diagnosis/ICD code and related treatment fields are required.\"},{\"question\":\"How often should the LMN be submitted and what are the limits?\",\"answer\":\"Submit the LMN once per plan year if it is accepted. A new LMN must be provided each year and cannot be approved indefinitely, and submitting does not guarantee reimbursement.\"}]","Letter of Medical Necessity - Request and Provider Certification | PDF"]