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:
(A) in total;
(B) by out-of-network providers that were covered as
in-network benefits;
(C) that were approved;
(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
(iii) adults;
(B) preauthorization requests approved for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(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
(iii) adults;
(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
(iii) adults;
(F) concurrent reviews for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(G) concurrent reviews approved for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(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
(iii) adults;
(I) concurrent reviews that were adversely determined
for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(J) retrospective reviews for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(K) retrospective reviews that were approved for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(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
(iii) adults; and
(M) retrospective reviews that were adversely determined
for:
(i) children ages 0 - 12;
(ii) adolescents ages 13 - 17; and
(iii) adults;
(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.
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