Skip to content
ClaimParrot
Open sample denial

Free tool · Parity

Mental health parity warning-sign checker

Answer short questions built on the warning signs the Department of Labor publishes. See which limits on mental-health and substance-use care may raise a parity issue, what to do next, and get a letter requesting the plan's NQTL comparative analysis.

By the ClaimParrot editorial team · Rules checked · 14 cited sources

Quick answer

Federal parity law (MHPAEA) bars plans from limiting mental-health and substance-use care more strictly than comparable medical care. Warning signs include prior authorization on almost all MH/SUD services, shorter approvals, fail-first rules and blanket exclusions of residential care or ABA. A warning sign is not a violation: the next step is to request the plan's comparative analysis.

Runs entirely in your browser. Nothing you type is sent to ClaimParrot or stored, and no patient details are needed: leave names and IDs as bracketed placeholders.

01 · The plan

Whose plan is it?

Decides which rules and complaint channels apply.

Jump to your results
Exclusions and limits
Does the plan exclude a whole type of mental-health or substance-use treatment that it covers in a similar form for medical conditions?

For example: Residential, partial hospitalization or IOP programs; ABA for autism; medications for opioid or alcohol use disorder; nutrition counseling for eating disorders.

Are there age limits, hour caps or visit or day limits on MH/SUD care that have no medical/surgical counterpart?

For example: An age cutoff for ABA; a cap on ABA hours per week; a yearly visit limit on therapy that medical office visits don't have.

Are copays or coinsurance for MH/SUD care higher than for comparable medical care in the same benefit classification?

For example: A specialist copay on every therapy visit while most medical office visits carry the primary-care copay.

Prior authorization, concurrent and retrospective review
Is prior authorization or concurrent review required for all or almost all MH/SUD benefits, but only for some medical/surgical benefits?

For example: Every outpatient therapy course, IOP admission or medication for addiction needs approval; most comparable medical services don't.

Are MH/SUD stays reviewed more often, or approved for shorter periods, than comparable medical stays?

For example: Residential or PHP reviewed every few days and approved a few days at a time, while skilled nursing or rehabilitation stays get longer approvals.

Do MH/SUD requests take longer, or go to manual review, while medical requests are automated or 'gold-carded'?

For example: Longer turnaround on behavioral-health authorizations; gold-card exemptions offered only to medical providers; a separate care manager for MH/SUD.

Are MH/SUD claims singled out for retrospective or prepayment review, or for extra record requests?

For example: Therapy claims routinely pended for records; post-payment audits that target behavioral-health codes.

Medical-necessity criteria and extra conditions
Must the patient fail, or complete, a lower level of care or another treatment before MH/SUD care is approved?

For example: Two failed outpatient attempts before residential SUD treatment; PHP required before inpatient; step therapy for medications.

Does the plan add conditions for MH/SUD care that medical care doesn't have?

For example: Required parental or family involvement; exhausting 'community resources' first; repeat autism testing; proof the patient is fully motivated.

Does the plan require proof of likely or measurable improvement, or exclude 'chronic' conditions, for MH/SUD care?

For example: Coverage only with substantial improvement within 90 days; residential denied as unlikely to improve; chronic-condition exclusions.

Must providers submit written treatment plans or re-evaluations on a schedule for MH/SUD care only?

For example: A treatment plan within 7 days with weekly review; resubmission every 6 months.

Are benefits denied because the patient did not complete an earlier course of treatment or left against medical advice?

For example: No coverage for a readmission after leaving residential early.

Has the plan refused or failed to provide the medical-necessity criteria it used, for example because they are 'proprietary'?

For example: No response to a written criteria request; a summary instead of the criteria; 'proprietary' given as the reason.

Network access and reimbursement
Is it hard to find in-network MH/SUD providers taking new patients, so patients pay out-of-network costs?

For example: Directory listings that don't answer or aren't taking patients; long waits; gap exceptions or single-case agreements that are hard to get.

Are network admission or credentialing rules stricter for MH/SUD providers, or is their pay set by a different method?

For example: Extra credentialing steps; a flat percentage discount for master's-level clinicians; rates far below the medical side's relative to Medicare.

Does the plan limit MH/SUD care by geography, facility type or licensure in ways it doesn't for medical care?

For example: In-state facilities only; extra licensure or accreditation required only for MH/SUD facilities; no telehealth for MH/SUD.

Must patients go through an Employee Assistance Program (EAP) before MH/SUD benefits start?

For example: Plan benefits only after a set number of EAP sessions.

Your results

Possible parity issues to raise

Answer any of the 17 questions; results update as you go.

A “yes” is a warning sign, not a finding. Whether a limit breaks the parity rules depends on how the plan treats comparable medical/surgical benefits in the same classification, which only the plan's own analysis shows. That is why the next step is to ask for it.

Where to get help

Next step

Request the comparative analysis

The letter lists every limitation you answered “yes” or “not sure” to, and asks for the plan's analysis of each, with the medical-necessity criteria.

[Your name, credentials]
[Practice name]
[Address] · [Phone] · [Email]

[Date]

Plan administrator, [Plan name]
Attn: [Plan administrator named in the Summary Plan Description, or the issuer's appeals unit]
[Address]

Re: Request for NQTL comparative analyses and medical-necessity criteria
Member: [Member name] · Member ID: [Member ID]
Service: [Service or level of care] · Benefit classification: Inpatient, in-network

To the plan administrator:

I am the treating provider and the authorized representative of a participant in the plan; a signed authorization is enclosed.

This request is made under ERISA section 712(a)(8) (added by the Consolidated Appropriations Act, 2021), which requires the plan to perform and document comparative analyses of its nonquantitative treatment limitations (NQTLs); ERISA section 104(b) and 29 CFR 2520.104b-1; 29 CFR 2590.712(d); and 29 CFR 2560.503-1(h)(2)(iii) and (m)(8). The Departments' FAQs About Mental Health and Substance Use Disorder Parity Implementation and the Consolidated Appropriations Act, 2021, Part 45 (Q6), confirm that participants and their authorized representatives may request these analyses.
Under ERISA section 502(c)(1), plan documents requested in writing from the plan administrator are due within 30 days.

Please provide the comparative analyses for the following NQTLs as applied to the service above, together with the corresponding analyses for medical/surgical benefits in the same classification:
  1. [Name the limitation, e.g. prior authorization for intensive outpatient treatment]

For each, please include:
  - the plan terms and any internal guidelines that impose the limitation on MH/SUD and on medical/surgical benefits;
  - the factors used to decide which benefits are subject to it, and the evidentiary standards behind those factors;
  - how it is applied in operation (for example, review frequency, length of approvals, approval and denial rates), for both sides;
  - the plan's conclusion on comparability and stringency, and who reached it;
  - the medical-necessity criteria used for this MH/SUD benefit, and for medical/surgical benefits in the same classification.

This request does not extend or waive any appeal deadline, and all rights to appeal, external review and complaints to the applicable regulator are reserved. If any document is withheld, please identify it and the reason.

Sincerely,

[Signature]
[Your name, credentials]

How it works

The rules behind the tool

Parity rules in force on October 14, 2026
RuleStatusWhat it means for an appeal
MHPAEA statute and the 2013 final ruleIn forceNQTLs on MH/SUD must be comparable to, and no more stringent than, those on medical/surgical benefits
CAA 2021 comparative-analysis dutyIn force (statutory)Plans must perform and document NQTL comparative analyses; participants can request them
2024 final rule (new provisions)Not enforced since May 15, 2025Don't build an argument on the parts new in 2024; a replacement proposal is pending
EBSA FAB 2026-03 (September 8, 2026)Current enforcement policyPriorities: exclusions, medical-necessity review, network adequacy
01

How do I use the parity checker?

Choose the plan type, then answer yes, no or not sure to each question about how the plan handles mental-health and substance-use care compared with medical care. Results update as you go. Every yes becomes a possible issue to raise, and every yes or not sure is listed in the comparative-analysis request letter.

  1. 01Pick the plan type. It decides which rules apply and where to complain. Medicare is shown for completeness: parity law does not apply to it.
  2. 02Answer from what you have seen: the plan document, the authorization history, denial letters and your billing data. Not sure is a fine answer.
  3. 03Read the possible issues. Each one cites the DOL document it comes from.
  4. 04Fill in the plan name, the service and the benefit classification, then copy, download or print the request letter.
  5. 05Send it to the plan administrator named in the Summary Plan Description (or to the insurer or Medicaid plan) and keep proof of delivery.
02

What does the parity law require of a health plan?

The Mental Health Parity and Addiction Equity Act requires that financial requirements and treatment limits on mental-health and substance-use benefits be no more restrictive than those on medical/surgical benefits in the same classification. For non-numeric limits such as prior authorization, the plan's processes and standards must be comparable and applied no more stringently.

Non-numeric limits are called nonquantitative treatment limitations (NQTLs). The 2013 rule's illustrative list includes medical management standards such as medical-necessity review, formulary design, network tier design, standards for provider admission to the network including reimbursement rates, fail-first or step-therapy rules, exclusions for failure to complete a course of treatment, and restrictions based on geography, facility type or provider specialty (29 CFR 2590.712(c)(4)).

The comparison runs within six benefit classifications: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care and prescription drugs. That is why the request letter asks you to name the classification.

Parity covers employer group health plans (some small employers are exempt), insured group and individual coverage, and, through separate rules, Medicaid managed care and CHIP (42 CFR Part 438, Subpart K). It does not apply to Medicare or Medicare Advantage.

03

Which parity rules are being enforced in 2026?

The statute, the 2013 final rule and the 2021 comparative-analysis duty apply. The 2024 final rule's new provisions have not been enforced since May 15, 2025. In court filings the Departments said they will propose a replacement rather than defend the 2024 rule, and in September 2026 said they intend to send that proposal for review by December 18, 2026.

On May 15, 2025, the Departments of Labor, HHS and the Treasury announced they would not enforce the parts of the 2024 rule that are new compared with the 2013 rule, for the length of the employer group ERIC's lawsuit plus 18 months. In a March 30, 2026 status report they said they would issue a new proposed rule, no later than December 31, 2026. Their September 30, 2026 report says they intend to send it to the Office of Information and Regulatory Affairs by December 18, 2026, with review expected to take about 90 days. As of October 14, 2026 no replacement proposal had been published.

On September 8, 2026, EBSA issued Field Assistance Bulletin 2026-03. It narrows enforcement to three areas with the highest potential for harm: separate treatment limits including exclusions; medical-necessity standards and review, focusing on prior authorization, concurrent review and retrospective review; and network adequacy, focusing on network admission standards and provider reimbursement methods. A companion tool lists the red flags EBSA sees most often; the checker's questions are drawn from it.

Base parity arguments on the statute, the 2013 rule and the comparative-analysis duty, not on provisions that are new in the 2024 rule. Check for a new proposed rule before relying on this page after December 2026.

04

What are the warning signs of a parity problem?

DOL's published red flags include prior authorization or concurrent review for all or almost all MH/SUD benefits, shorter authorization periods, fail-first rules, blanket exclusions of residential, IOP, PHP, ABA or addiction medications, MH/SUD-only conditions such as required family involvement, and stricter network admission or lower reimbursement for MH/SUD providers.

The older joint DOL/HHS Warning Signs document makes the key point plainly: these terms do not automatically violate the law, but the plan has to be able to show its analysis. A yes in the checker is therefore a question for the plan, not an answer.

How the checker's questions map to DOL's lists
AreaExample warning signsDOL source
Exclusions and limitsBlanket exclusion of residential, PHP, IOP or ABA; age limits on ABA; MH/SUD-only visit limitsFAB 2026-03; 2026 red flags
Prior authorization and reviewPrior authorization on almost all MH/SUD care; review every few days; manual review only for MH/SUD2026 red flags; Warning Signs I
Criteria and conditionsFail-first; probability of improvement; treatment-plan rules; exclusions for not completing treatmentWarning Signs II to V; 2026 red flags
NetworkHard-to-reach in-network providers; stricter credentialing; different reimbursement methodsFAB 2026-03; 2026 red flags
05

Can a patient or provider request the plan's NQTL comparative analysis?

Yes. Since the Consolidated Appropriations Act, 2021, plans must perform and document comparative analyses of their NQTLs. The Departments' FAQs Part 45 (April 2021) say participants, beneficiaries and enrollees, or their authorized representatives, may request them, including a provider acting as the patient's authorized representative.

For ERISA plans the FAQ ties the right to ERISA section 104(b), the parity disclosure rule at 29 CFR 2590.712(d)(3) and the claims rules. Plan instruments requested in writing from the plan administrator are due within 30 days under ERISA section 502(c)(1). The letter also asks for the medical-necessity criteria for the MH/SUD benefit and for medical/surgical benefits in the same classification, which the plan must disclose on request.

For Medicaid managed care, the letter cites the Medicaid parity rules instead: the plan must disclose its medical-necessity criteria on request (42 CFR 438.915(a)), and the state must make its parity compliance documentation available to the public (42 CFR 438.920(b)).

06

Where can I complain about a possible parity violation?

It depends on who regulates the plan. Private employer plans: the Department of Labor's EBSA. Insured individual and group coverage: the state insurance department. State and local government employer plans: CMS. Medicaid managed care: the plan appeal, the state fair hearing and the state Medicaid agency. Medicare has its own appeal process.

  • EBSA: submit an inquiry or complaint online or call 1-866-444-3272.
  • State insurance departments: the NAIC directory links each state's complaint page.
  • CMS parity help line for non-federal governmental plans: 1-877-267-2323 extension 6-1565, or phig@cms.hhs.gov.
  • Medicaid: appeal to the plan, then request a state fair hearing; the state must ensure its managed care plans comply with the parity rules.
  • External review: under the federal process, whether a group health plan complied with the parity rules for NQTLs is itself eligible for review (request tool).
Fictional example

A residential exclusion and three-day approvals

Cedar Ridge Treatment Center (fictional) treats a patient covered by a large self-funded employer plan. The plan approves residential SUD treatment three days at a time with daily notes required, while the provider's medical rehabilitation colleagues report two-week approvals for skilled nursing stays.

The utilization review lead answers yes to the review-frequency and prior-authorization questions and not sure to the network-admission question. The checker lists three possible issues and generates a letter asking for the comparative analyses of concurrent review frequency, authorization periods and network admission standards for inpatient in-network benefits.

The letter goes to the plan administrator with the patient's signed authorization, alongside the appeal of the latest step-down. The program notes in the appeal that the analysis has been requested.

Names, dates, payers and amounts are invented for illustration.

Where ClaimParrot fits

What a ClaimParrot packet adds

  • An appeal packet answers the denial itself; send this tool's request letter alongside it when parity questions come up.
  • Every packet is checked by a person and costs $29, or $99 for level-of-care denials; the first one is free (pricing).
  • Requests are de-identified: no PHI is accepted and no BAA is needed (Trust & security).

Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.

Common questions

Frequently asked questions

Does a yes in the checker mean the plan broke the law?

No. A yes means the plan does something DOL lists as a warning sign. Whether it violates the parity rules depends on how the plan designs and applies the same kind of limit to comparable medical/surgical benefits in the same classification. Only the plan's comparative analysis shows that, which is why the next step is to request it.

Is the 2024 parity rule still in effect?

It is on the books, but the Departments have not enforced its new provisions since May 15, 2025, and told the court they will propose a replacement. The statute, the 2013 rule and the 2021 comparative-analysis duty still apply, and EBSA's FAB 2026-03 sets current enforcement priorities.

Does parity apply to Medicare Advantage?

No. The federal parity law does not apply to Medicare, either original Medicare or Medicare Advantage. Medicare Advantage denials go through the Medicare appeal process; the appeal deadline calculator shows those clocks.

Is a blanket exclusion of ABA or residential treatment a parity issue?

It is the first of EBSA's three enforcement priorities: plans cannot apply blanket exclusions of treatments for covered MH/SUD conditions where similar treatments are covered for medical/surgical conditions. DOL's 2026 red-flag list names exclusions of ABA, residential, IOP and PHP programs, and medications for addiction.

What if the plan says its comparative analysis is confidential?

The Departments' FAQs Part 45 say participants and their authorized representatives may request the analyses. If the plan refuses or doesn't answer, note the date of the request in your appeal and raise it with the regulator for the plan type. Don't let the request hold up the appeal deadline.

Sources

Primary sources and references

  1. 29 CFR 2590.712: MHPAEA parity requirements and criteria disclosure · eCFR (National Archives) · checked
  2. 45 CFR 146.136: MHPAEA parity requirements for insured group coverage · eCFR (National Archives) · checked
  3. EBSA Field Assistance Bulletin 2026-03: guiding principles for MHPAEA NQTL enforcement (September 8, 2026) · U.S. Department of Labor, EBSA · checked
  4. Identifying Potential Problems: possible MHPAEA compliance problems (September 2026) · U.S. Department of Labor, EBSA · checked
  5. Warning Signs: plan or policy NQTLs that require additional analysis · U.S. Departments of Labor and HHS · checked
  6. FAQs About MHPAEA and CAA 2021 Implementation, Part 45 (Q6: who may request NQTL analyses) · U.S. Departments of Labor, HHS and the Treasury · checked
  7. Statement regarding enforcement of the 2024 MHPAEA final rule (May 15, 2025) · U.S. Department of Labor, EBSA · checked
  8. ERIC v. HHS, No. 25-cv-136 (D.D.C.), joint status report of September 30, 2026 · U.S. District Court for D.C. (via Georgetown Litigation Tracker) · checked
  9. 29 CFR 2590.715-2719: internal claims, appeals and external review (group health plans) · eCFR (National Archives) · checked
  10. 42 CFR 438.915: Medicaid managed care parity disclosure · eCFR (National Archives) · checked
  11. 42 CFR 438.920: state parity compliance documentation · eCFR (National Archives) · checked
  12. Mental Health Parity and Addiction Equity Act (CMS help line for non-federal governmental plans) · CMS · checked
  13. Ask EBSA: submit a health plan inquiry or complaint · U.S. Department of Labor, EBSA · checked
  14. Mental Health Parity at a Crossroads (parity does not apply to Medicare) · KFF · checked

General information, not legal or medical advice. The denial notice, the plan documents and state law control; state law can give more time or more rights than the federal floor shown here. Read our editorial policy.

Doing this for every denial in the queue?

Send one de-identified denial and get the appeal letter draft, evidence checklist and deadline plan back, checked by a person before it reaches you. $29 per appeal packet, $99 per level-of-care packet; your first packet is free.

Send a denialSee pricingAll free tools

Free tools.No patient data needed.

Send a denial