Scenario

I would like to know what mental health and substance use disorder benefits and what medical/surgical benefits are subject to preauthorization. My plan says they are all based on clinical utilization review guidelines.

Where to start

Utilization review criteria related to both mental health and substance use disorder and medical/surgical benefits provided under the plan or coverage.

You can request the plan’s specific utilization review criteria, and other materials, which could include:

  1. Standards developed by an outside organization. Many health plans use third-party standards to determine the level of care required by an individual plan participant;
  2. Criteria which may be developed by the issuer or third-party administrator, for both MH/SUD benefits and medical/surgical benefits;
  3. Information on how the plan determines when it is appropriate to depart from the criteria developed by an outside organization for both medical/surgical and MH/SUD benefits (if the plan departs from these criteria).

You can also request any analyses the plan has performed to verify whether the plan complies with MHPAEA.

When can I get these documents?

Promptly, but generally not later than 30 days after your request. Shorter time limits apply in the case of urgent care claims.