MHPAEA Non-Quantitative Treatment Limits Summary Report (SilverSummit Health Plan)
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State-mandated summary report evaluating SilverSummit Health Plan's compliance with MHPAEA non-quantitative treatment limits (NQTLs), including as-written and in-operation analyses of utilization management, network adequacy, credentialing, reimbursement, and claims for MH/SUD vs Med/Surg benefits.
Findings of non-comparable application of NQTLs across utilization management, network adequacy, credentialing, reimbursement, and claims with recommended remediation options.
Deficiencies in 'as written' documentation and incomplete Comparative Analysis Report supporting data.
Concurrent Review stringency discrepancy: MH/SUD inpatient cases required CR more frequently than Med/Surg (38% vs 29%).
Prior Authorization denial disparity with higher denials for MH/SUD compared to Med/Surg.
Reimbursement disparities between Med/Surg and MH/SUD for common procedure codes.
NQTL Findings and Required Remedies
inv-01: NQTL Findings and Violations
Findings from the 'as written' documentation review and 'in operation' data analytics identified deficiencies and violations in application of NQTLs across utilization management and network adequacy.
ALL of the following
- Covered services list and reconciliation issues: The list of covered services to which prior authorization applies could not be reconciled to the supporting Certificates of Coverage or other supporting documentation provided.
- Certificates of Coverage (COC) inconsistencies: Consumers, providers, and vendors are not given consistent and clear information about how prior authorization (PA), concurrent review (CR), and retrospective review (RR) are submitted and handled.
- Comparative Analysis Report gaps: The Company's Comparative Analysis Report was incomplete; supporting data samples for 'in operation' policy sections lacked supporting evidence to substantiate analysis statements.
ALL of the following
- Higher OON rates for MH/SUD UM services: 'In operation' data show MH/SUD services that require UM have a higher out‑of‑network (OON) rate than Med/Surg services that require UM.
- Higher CR requirement for MH/SUD inpatient: 'In operation' data show MH/SUD inpatient services have a significantly higher concurrent review (CR) requirement than Med/Surg inpatient services (29% Med/Surg vs 38% MH/SUD).
ALL of the following
- Utilization Management NQTL Violation: MH/SUD inpatient UM cases required CR more frequently than Med/Surg inpatient cases (29% Med/Surg vs 38% MH/SUD), rising to the level of a violation of 45 CFR 146.136 because application is not comparable and is more stringent for MH/SUD.
- Network Adequacy NQTL Violations: Multiple analytics findings demonstrate network adequacy and access disparities — differences in OON UM case percentages, in‑network shares, and denial rates for PA‑required claims — that are not comparable between MH/SUD and Med/Surg and therefore constitute violations.
ALL of the following
- Claims composition: MH/SUD claims comprised approximately 6% of claims volume; in‑network shares were 80% INN / 20% OON for Med/Surg versus 79% INN / 21% OON for MH/SUD.
- OON denial and UM case rates: Company denial rate as OON was 25% for Med/Surg versus 27% for MH/SUD; approximately 5% of total UM cases were MH/SUD, with 31% applied to OON providers compared to 27% for Med/Surg OON providers.
- Prior Authorization denial disparity: For denied claims that required PA, denial rate was 4% for Med/Surg versus 7% for MH/SUD.
inv-02: NQTL findings and remedies
Identified areas where the Company's processes or operations are not comparable between MH/SUD and Med/Surg, and recommended remedies to address operational gaps and violations.
ALL of the following
- Finding: Higher frequency of OON denials and slightly lower INN access for MH/SUD compared to Med/Surg, indicating network adequacy NQTL applied more stringently to MH/SUD (INN: Med/Surg 80% vs MH/SUD 79%; OON: Med/Surg 20% vs MH/SUD 21%).
- Remedies: Perform targeted market conduct examination of network adequacy for MH/SUD; require the Company to submit corrective action plans to increase in‑network MH/SUD provider participation and reduce OON reliance; consider reprocessing affected claims as appropriate and assess administrative remedies if noncompliance persists.
ALL of the following
- Remedies: Require the Company to reconcile fee schedules and provide documentation explaining reimbursement methodologies; mandate submission of an action plan to address pay disparities, including timelines and measurable benchmarks to improve MH/SUD provider reimbursement and network participation.
ALL of the following
- Finding: Prior authorization denials and UM application disproportionately affected MH/SUD (denial rate for PA: Med/Surg 4% vs MH/SUD 7%); 'as written' materials lacked clear guidance on PA/CR/RR processes.
- Remedies: Require the Company to update Certificates of Coverage and member/provider communications to clearly explain PA/CR/RR submission and handling; require reprocessing review for denials where improper PA application is identified; require the Company to provide complete Comparative Analysis Report supporting data and define medical management ratios and criteria used in 'in operation' analyses.
ALL of the following
- Recommendation: Division may conduct targeted market conduct exam activities, demand reprocessing of claims where appropriate, require corrective action plans with timelines, and consider administrative fines or other enforcement actions for failure to remediate.
- Recommendation: Company should cross‑reference Comparative Analysis Reports (CARs), provide complete supporting documentation for 'in operation' findings, and define the metrics and ratios used for UM analyses to enable transparent monitoring and validation.
Codes, Reimbursement Disparities, and Comparison Thresholds
| No codes listed |
| 99213 | E&M office visit — average Med/Surg $85.51 vs MH/SUD $69.38 (21% difference) |
| 99214 | E&M office visit — average Med/Surg $119.17 vs MH/SUD $82.14 (37% difference) |
| 99215 | E&M office visit — average Med/Surg $184.90 vs MH/SUD $110.84 (50% difference) |
| 90833 | MH/SUD psychotherapy with E/M — average Med/Surg $197.55 vs MH/SUD $184.62 (7% difference) |
Utilization Management Findings and Provider Impacts
Utilization Management (PA/CR/RR) review and findings
Report reviewed Prior Authorization (PA), Concurrent Review (CR), and Retrospective Review (RR) processes as part of utilization management and found inconsistencies between 'as written' documentation and 'in operation' application, including inability to reconcile the list of covered services subject to PA with Certificates of Coverage, unclear guidance in Certificates of Coverage about how PA/CR/RR reviews are submitted and handled, and an incomplete Comparative Analysis Report lacking supporting in-operation data.
- List of covered services subject to PA could not be reconciled to supporting Certificates of Coverage.
- Certificates of Coverage did not provide consistent, clear information about submission and handling of PA, CR, and RR.
- Comparative Analysis Report lacked supporting data samples for in-operation sections.
Concurrent Review stringency discrepancy
Data analytics showed MH/SUD inpatient UM cases required Concurrent Review more frequently than Med/Surg inpatient cases (38% vs 29%), a disparity the report identifies as a violation of 45 CFR 146.136 because CR is applied more stringently to MH/SUD than to Med/Surg.
- 29% of Med/Surg inpatient UM cases required CR versus 38% of MH/SUD inpatient UM cases.
- Finding characterized as a violation of 45 CFR 146.136 due to non-comparable application of the NQTL.
Prior Authorization denial disparity
Claims analysis found higher denial rates for services requiring prior authorization for MH/SUD compared to Med/Surg: 7% versus 4%, and identified prior authorization as a leading reason for MH/SUD denials.
- Denial rate for claims that required PA: Med/Surg 4% vs MH/SUD 7%.
- Claims analysis identified Prior Authorization as a top reason for MH/SUD denials; claims data used to validate in-operation disparities.
Key Terms and Definitions
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