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Parity & Equity (MHPAEA) Compliance Checker Disputing the Decisions that Affect Your Bottom-Line . Patrick Gauthier, Director. Parity & Equity.
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Disputing the Decisions that Affect Your Bottom-Line
Patrick Gauthier, Director
Non-quantitative treatment limitations include medical management, network inclusion process and standards, step therapy (fail first), and establishment of Usual, Customary and Reasonable rates of reimbursement.
Processes, strategies, evidentiary standards, or other factors used in applying the non-quantitative treatment limitations to MH/SUD benefits to MH/SUD in a classification are comparable to and applied no more stringently than what is applied to medical/surgical benefits except to the extent that recognized clinically appropriate standards of care may permit a difference.
(1) Ambulatory patient services.
(2) Emergency services.
(4) Maternity and newborn care.
(5) Mental health and substance use disorder services, including behavioral health treatment.
(6) Prescription drugs.
(7) Rehabilitative and habilitative services and devices.
(8) Laboratory services.
(9) Preventive and wellness services and chronic disease management.
(10) Pediatric services, including oral and vision care.
Denials of reimbursementcan occur for administrative and/or medical necessity reasons at the time of claims adjudication/processing
Denials and Appeals
Denials of coverage and/or benefitscan occur at various Utilization Management or UR junctures throughout the episode
Service Episode Timeline
Important Stakeholders Include:
Expediting Appeals: Appeals can move more quickly (1) if the patient is in the hospital or (2) if the service has not yet been provided.
Emergent/Urgent Appeals (concerning the life and wellbeing of the patient will be “fast-tracked” by the plan in order to respond within 1-3 days depending upon circumstances. If the need is emergent or urgent, use this mechanism and be sure to let the plan know.
Then, within 1 day, the plan must indicate to the claimant whether the appeal meets criteria for external review. If information is missing, the plan must enable the claimant by providing instructions and time to re-submit the appeal correctly.
Once the claim is deemed appropriate for external review, the plan will forward it within 5 days to an Independent Review Organization (IRO) for their review. The IRO has 45 days.
888-898-3280 ext. 802