CMS-10307 - Crosswalk of Template Changes

Crosswalk of Changes

Medical Necessity and Claims Denial Disclosures under MHPAEA

(CMS-10307/OMB Control No. 0938-1080)

Section Edited	Revision (Red indicates modified Language)
Title	FORM TO REQUEST DOCUMENTATION FROM AN EMPLOYER-SPONSORED HEALTH PLAN OR ANA GROUP OR INDIVIDUAL MARKET INSURER CONCERNING TREATMENT LIMITATIONS
Background	This is a tool to help you request information from your employer-sponsored health plan or your group or individual market insurer regarding treatment limitations that may affect your access to mental health or substance use disorder benefits. You can use this form to request: general information about treatment limitations or specific information about limitations that may have resulted in denial of your benefits. An example of a request for general information might be a request for the plan’s preauthorization policies for medical/surgical and mental health treatments. An example of a request for specific information related to a denial of benefits based on a failure to show medical necessity might be a request for the internal medical necessity guidelines used to deny your claim. Your plan or insurer is required by law to provide you this information in certain instances, and the information will help you determine if the coverage you are receiving complies with the law. General information about treatment limitations, like your plan’s preauthorization policies for both medical/surgical and mental health treatment. Specific information about why benefits were denied. For example, you can ask about the criteria for “failure to show medical necessity” that your health insurance company may have used to deny your claim.
Background	Added: Your plan or insurer is required by law to provide you this information in certain instances. In some cases, a request can result in more information than you may want. Talk to your plan or insurer about what documents you wish to request, and, if you prefer, how you can receive the documents electronically.
Background	This generally means that financial requirements and treatment limits limitations applied to mental health andor substance use disorder benefits mustcannot be at least as generous asmore restrictive than the financial requirements and treatment limits applied to medical and surgical benefits. In other words, treatment limits cannot be applied to mental health and substance use disorder benefits unless those limits are comparable to limitslimitations applied to medical and surgical benefits. The types of limits covered by parity protections include: Financial requirements—such as deductibles, copayments, coinsurance, and out-of-pocket limits; and Treatment limitslimitations—such as limits on the number of days or visits covered, or other limits on the scope or duration of treatment (for example, being required to get prior authorization).
Background	If you, a family member, or someone you are helping obtains health coverage through a private employer health plan, federal law requires the plan to provide certain plan documents about your or their benefits, including coverage limitations on yourthose benefits, at youron request. For example, you may want to obtain documentation as to why your health plan is requiring pre-authorization for visits to a therapist before it will cover the visits. Generally, the plan private employer plans must provide the documents you request within thirty (30) calendar days of the plan’s receipt of your request. Contact your health plan or health insurance company directly to submit your request.
Background	This form willis designed to help you request information from your plan about treatment limitslimitations. Many common types of treatment limits are listed on this form. If the type of treatment limitslimitations being imposed by your plan does not appear on the list, you may insert a description of the treatment limitlimitation about which you would like more information about under “Other.”
Instructions	Complete the attached form to request general information from your plan or insurer about coveragetreatment limitations or specific information about why your mental health or substance use disorder benefits were denied. This information canmay help you appeal a claim denial, but you must separately initiate the plan’s general review and appeals process if you want to appeal the claim denial with your plan or insurer the claim denial. You do not have to use this form to request information from your plan. Consult your summary plan description (SPD) or certificate of coverage to see how to request information from the plan, or how to appeal a denied claim.
Instructions	If you are helping someone with obtainingrequest information about his/her health coverage, a plan or insurer may require you are often requiredto submit an authorization along with this form, with your request for information, additional documentation signed by the person you are helping (if you have not submitted one beforehandalready done so).
Instructions	If you have any questions about this form and you are enrolled in a private employer health plan, you may visit the Employee Benefits Security Administration’s (EBSA’s) website at www.dol.gov/ebsa for answers to common questions about your private employer health planplans.
Instructions	You can also use this form if you are enrolled in coverage that is not through a private employer health plan,—for example, if you have individual health coverage or coverage sponsored by a public sector employer, like a city or state government. You may contact the Centers for Medicare & Medicaid Services (CMS) at [email protected] or 1-877-267-2323 ext. 6-156561565 for questions about your individual health coverage or public sector health plan.
Form	Added: NOTE: This disclosure request form is NOT designed to initiate a formal claim for benefits or an appeal of a denied claim; however, the information obtained through this form may help you appeal a medical claim denial with respect to your mental health and substance use disorder benefits. Submitting this form is voluntary and does NOT replace your health plan’s claims or appeals process.
Form	(If you are a provider or another representative who is authorized to request information for the individual enrolled in the plan, complete this sectionprovide the information below.)
Form	(Check the box to indicate whether your request is for Complete this section if you’re requesting general information or specific information related to your claim or denial for benefitsabout treatment limitations.)
Form	The following specific treatment for my mental health condition or substance use disorder: ____________________________.
Form	Added: (Complete this section if you’re requesting specific information about limitations that led to a denial of benefits.)
Form	I was advised that the treatment was experimental or investigational;investigative.
Form	The plan is requiring me to try a different treatment before authorizing the treatment that my doctor or therapist recommends.
Form	The plan’s prescription drug formulary design willdoes not cover the medication my doctor is prescribing.
Form	I am not sure howwhether my plan calculatesplan’s calculation of payment for out-of-network services, such as its methods for determining usual, customary and reasonable charges, complies with parity protections.
Form	Because my health coverage is subject to the parity protections, financial requirements or treatment limitslimitations cannot be applied to mental health andor substance use disorder benefits unless those limits are comparable to limitsfinancial requirements or treatment limitations applied to medical and surgical benefits. Therefore, for the limitations or terms of the benefit plan specified above, within thirty (30) calendar days offrom the date appearing onof receipt of this request, I request that the plan:
Form	1. Provide the specific plan language regarding the limitation(s) and identify all of the medical/surgical and mental health andor substance use disorder benefits to which it applies in the relevant benefit classification described in the regulations under the Mental Health Parity and Addiction Equity Act;
Form	2. Identify the factors used in the development of the limitation(s) (examples of factors include, but are not limited to, excessive utilization, recent medical cost escalation, high variability in cost for each episode of care, and safety and effectiveness of treatment);
Form	3. Identify the sources (including any processes, strategies, evidentiary standards) used to evaluate the factors identified above. Examples of evidentiary standards include, but are not limited to, the following:
Form	Safety and efficacy of treatment modality as defined by 2 random clinical trials required to establish that a treatment is not experimental or investigationalinvestigative;
Form	4. Identify the methods and analysis used in the development of the limitation(s); and
Form	5. Provide any evidence and documentation to establish that the limitation(s) is applied no more stringently, as written and in operation, to mental health and substance use disorder benefits than to medical and surgical benefits.
Form	Deleted: I am an authorized representative requesting information for the following individual enrolled in the plan: ______________________________________. Attached to this request is an authorization signed by the enrollee.
Form	Added: Claim Number (if seeking information regarding a specific claim)

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