Ask for the parity comparison for a mental health denial
A written request for the plan's mental health parity comparison and the medical necessity criteria behind a mental health or substance use denial, so you can test the decision against the parity law.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when the denial is for mental health or substance use care and you want the plan to show that the limit applied is no stricter than the limits on medical and surgical care. It is a records request, not an appeal. Parity rules do not reach every plan: small-employer group plans are outside the Employee Retirement Income Security Act (ERISA) parity section, and some self-funded government plans have opted out. Since 15 May 2025 the federal agencies have not been enforcing the new parts of the 2024 parity rule; the law itself, the 2013 rule and the comparative-analysis duty remain.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan administrator]
Re: Ask for the parity comparison for a mental health denial Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am covered by [Name of the health plan], member ID [Member ID]. On [Date on the denial notice] the plan denied my claim [Claim or reference number] for [The care or drug that was denied], which is care for a mental health or substance use condition. The stated reason was: [The reason the denial gives]. I am asking for documents. This is not my appeal.
Federal law requires a plan that covers both medical and surgical benefits and mental health or substance use disorder benefits to apply limits to the mental health benefits that are "no more restrictive than the predominant" limits applied to "substantially all" medical and surgical benefits. Since February 2021 the law also requires a plan that imposes nonquantitative treatment limitations on those benefits, such as prior authorization or medical necessity criteria, to "perform and document comparative analyses" of how those limits are designed and applied.
Please send me, free of charge:
1. The comparative analysis the plan has performed and documented for the limit used to deny my care ([The limit the plan used]), covering mental health or substance use disorder benefits and medical and surgical benefits. 2. The medical necessity criteria the plan uses for mental health and substance use disorder benefits, and for medical and surgical benefits. 3. The processes and evidentiary standards used to apply that limit. 4. The reason for the denial, in writing, and my claim file.
If my plan is covered by the Employee Retirement Income Security Act (ERISA), federal guidance says a person who has received a denial may request these as documents relevant to the claim, and federal rules call for these documents to be furnished within 30 days of a request. Please reply in writing within 30 days of the date of this letter, and confirm the date you received this request so that I have proof of delivery.
Enclosures: 1. Copy of the denial letter
Sincerely, [Your name]
Before you send it
Send it to the address the plan gives for appeals or member records. Look on your denial notice, your member card or the plan's website. If you cannot find one, call the member services number on your card, ask where written requests go, and write down the date, the person's name and any reference number. To prove it arrived, use certified mail with a return receipt, or fax it and keep the confirmation page, or send it through the plan's online portal and take a screenshot that shows the date. Keep a copy of the letter. Send a copy to the plan's appeals address as well if your appeal is also due.
What to enclose
- Copy of the denial letter
What happens next
- You: send the letter and keep the proof of delivery.
- Plan: if your plan is covered by ERISA, the federal rules call for the parity documents within 30 days of a request. That 30-day rule applies to ERISA plans; for other plans, say in your appeal that you asked and by what date.
- You: do not wait for these documents if your appeal is due. For most job-based and individual plans you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. A grandfathered individual policy may give less. Check the date on your notice, which controls.
- You and your clinician: when the documents arrive, compare the criteria and limits for mental health care with those for medical and surgical care. If they differ, say so in your appeal; a denial that turns on a parity question can go to federal external review.
The rule behind this
- 29 U.S.C. 1185a(a)(3)(A), (a)(4), (a)(8)(A) (parity, criteria and comparative analyses)
- 29 CFR 2590.712(d) (disclosure of criteria and reasons)
- 42 U.S.C. 300gg-26 (group and individual insurance)
- Departments' frequently asked questions, Part 45, Question 6
- Departments' statement on enforcement of the 2024 parity rule
Sources
- 29 U.S.C. 1185a(a)(3)(A), (a)(4), (a)(8)(A) (parity, criteria and comparative analyses)
- 29 CFR 2590.712(d) (disclosure of criteria and reasons)
- 42 U.S.C. 300gg-26 (group and individual insurance)
- Departments' frequently asked questions, Part 45, Question 6
- Departments' statement on enforcement of the 2024 parity rule
Denial reasons this answers
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.
- Denial reason
Level of care
Your plan agrees you need treatment but says a less intensive setting would do. For example, outpatient care instead of residential care, or a lower-intensity program instead of a hospital stay.
- Denial reason
Visit or benefit limit reached
Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.