Current through Reg. 50, No. 13; March 28, 2025
Within the "MH/SUD Parity Rule Division 2 Data Collection
Reporting Form" template, in the worksheet titled "Claims and Utilization
Review," for medical/surgical, MH/SUD, and for each of the classifications
listed in §
21.2425(c) of
this title (relating to Claims and Utilization Review: Reporting
Classifications), an issuer must provide the following aggregate claims and
utilization review data for the reporting year:
(1) the number of reported claims for
services or benefits that have been provided:
(B) by out-of-network providers that were
covered as in-network benefits;
(D) that were
administratively denied; and
(E)
that were adversely determined;
(2) the number of utilization reviews,
including:
(A) preauthorization requests for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(B) preauthorization requests approved for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(C) preauthorization requests that received a
peer-to-peer or physician-to-physician review for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(D) preauthorization requests that were
subject to a fail-first or step therapy requirement;
(E) preauthorization requests that were
adversely determined for:
(i) children ages 0
- 12;
(ii) adolescents ages 13 -
17; and
(F) concurrent reviews for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(G) concurrent reviews approved for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(H) concurrent reviews that received a
peer-to-peer or physician-to-physician review for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(I) concurrent reviews that were adversely
determinedfor:
(i) children ages 0 -
12;
(ii) adolescents ages 13 - 17;
and
(J) retrospective reviews for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(K) retrospective reviews that were approved
for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(L) retrospective reviews that received a
peer-to-peer or physician-to-physician review for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(M) retrospective reviews that were adversely
determined for:
(i) children ages 0 -
12;
(ii) adolescents ages 13 - 17;
and
(3) the number of
adverse determinations that were internally appealed that:
(A) then received a peer-to-peer or
physician-to-physician review on internal appeal;
(B) were again adversely determined on
internal appeal; and
(C) were
reversed on internal appeal; and
(4) the number of adverse determinations
independently reviewed that were:
(A) upheld
on independent review; and
(B)
reversed on independent review.
