Medical Necessity Disclosure Under MHPAEA and Claims Denial Disclosure Under MHPAEA (CMS-10307)

OMB 0938-1080

Medical Necessity Disclosure under MHPAEA The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (P.L.110-343) requires that group health plans and group health insurance issuers offering mental health or substance use disorder (MH/SUD) benefits in addition to medical and surgical (med/surg) benefits ensure that that they do not apply any more restrictive financial requirements (e.g., co-pays, deductibles) and/or treatment limitations (e.g., visit limits) to MH/SUD benefits than those requirements and/or limitations applied to substantially all med/surg benefits.Medical Necessity Disclosure under MHPAEA section 512(b) specifically amends the Public Health Service (PHS) Act to require plan administrators or health insurance issuers to provide, upon request, the criteria for medical necessity determinations made with respect to MH/SUD benefits to current or potential participants, beneficiaries, or contracting providers. The Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (75 FR 5410, February 2, 2010) sets forth rules for providing criteria for medical necessity determinations. The final rules retain the provisions from the interim final rules and extend them to small employers and the individual market. CMS oversees non-Federal governmental plans or related health insurance and health insurance plans offered in the individual market.MHPAEA section 512(b) specifically amends the Public Health Service (PHS) Act to require plan administrators or health insurance issuers to supply, upon request, the reason for any denial of payment for MH/SUD services to the participant or beneficiary involved in the case.

The latest form for Medical Necessity Disclosure Under MHPAEA and Claims Denial Disclosure Under MHPAEA (CMS-10307) expires 2021-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10307 Disclosure Request Form Form and Instruction
CMS-10307 - Supporting Statement 30-day.docx Supporting Statement A
Disclosure Request Form Form and Instruction
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Paper]
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Electronic]
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Paper]
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic]
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Paper]
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Electronic]
Disclosure under MHPAEA [Processed By Issuer in the Individual Market]
Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper]
Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]
Claims Denial Disclosure under MHPAEA [Processed In-House] [Paper]
Claims Denial Disclosure under MHPAEA [Processed In-House] [Electronic]

All Historical Document Collections

202102-0938-014 Approved with change	Revision of a currently approved collection	2021-02-24
201908-0938-016 Approved without change	No material or nonsubstantive change to a currently approved collection	2019-08-30
201712-0938-008 Approved with change	Reinstatement without change of a previously approved collection	2017-12-13
201311-0938-020 Approved without change	Existing collection in use without an OMB Control Number	2013-11-14
200912-0938-008 Preapproved	New collection (Request for a new OMB Control Number)	2009-12-17

OMB Details

Claims Denial Disclosure under MHPAEA [Processed In-House] [Electronic]

Federal Enterprise Architecture: Health - Health Care Services