Scenario
My plan will not authorize a treatment recommended by my health provider (in this case, a specific medication that was prescribed). If treatment is not authorized, my plan will not pay or will reduce payment.
Where to start
The plan’s requirement for preauthorization, including utilization review standards, and its medical criteria or “other evidentiary standards, procedures, or strategies” used to develop its utilization review standards.
To determine whether MH/SUD and medical/surgical benefits are being provided comparably, you may request information regarding the basis for determining what MH/SUD and medical/surgical benefits are subject to utilization review. This includes information about the medical guidelines, costs, or other factors supporting the basis for the application of the utilization review standard. This may include the following:
- Medical necessity criteria;
- Utilization review standards (see the previous Scenario);
- Other factors related to imposing a utilization review requirement on a particular MH/SUD benefit being sought, such as cost or whether it is considered clinically effective.
For example, plans and insurers often use reports of pharmacy and therapeutics committees to decide how to cover prescription drug benefits. These reports should be requested in order to determine parity in prescription drug benefits.
You also can 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.
