Paused
- New 2024 text: the meaningful benefits standard, the data evaluation rules, the six-element analysis format, the ban on discriminatory factors and evidentiary standards [1]
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White paper · Mental health parity
MHPAEA parity claims: a provider playbook for 2026
Short answer: federal enforcement of the 2024 parity rule is paused until a court decision plus 18 months. The statute, the CAA, 2021 comparative analysis duty and your remittance data are not. Build the evidence file from the 835, send the contract claim first, the parity argument second.
Exhibits A to D · built from the 835
6 elements · NQTL comparative analysis
Contract claim first · parity second
Edition
1 · 2026
Focus
Parity claims
Exhibits
A to D, from the 835
Audience
BH groups · CMHCs
Clock
10 business days
Regulators
DOL · state · Medicaid
May 152025
Nonenforcement of the 2024 rule's new portions during reconsideration [2]
6elements
In each NQTL comparative analysis under the 2024 rule; the statutory duty continues [1]
10business days
Plan clock to produce a comparative analysis on request [1]
19 to 22%
Therapy-code underpayment in our parity case study, versus 1.2% on E/M
Two pages, one line that matters to a provider
On May 15, 2025 Labor, HHS and the Treasury said they will not enforce the 2024 MHPAEA final rule for a failure before a final ERIC decision plus 18 months. The relief covers only what is new relative to the 2013 rule; statutory obligations under the CAA, 2021 continue, and plans may rely on the 2013 rule and FAQs Part 45 [2].
- 1Sep 9, 20242024 final rule issued; effective November 22, 2024
- 2Jan 17, 2025ERIC files suit in the D.C. district court
- 3May 15, 2025Nonenforcement statement issued [2]
- 4Decision + 18 monthsEarliest end of the federal pause
Running: the statute
- Financial requirements and treatment limits on MH/SUD benefits no more restrictive than the predominant ones on substantially all medical/surgical benefits in the same classification
Running: CAA, 2021
- Plans that impose NQTLs on MH/SUD benefits must perform and document comparative analyses and produce them on request [1]
Running: the states
- State parity statutes and state enforcement against issuers; HHS encouraged, but did not require, states to adopt a similar pause [2]
Takeaway
A provider never had standing to run a federal parity audit. What a provider always had was the remittance data that shows the harm. Nothing in May 2025 changed that.
Six elements, and the provider data that tests each one
A nonquantitative treatment limitation is any non-numeric limit on scope or duration: prior authorization, concurrent review, medical necessity criteria, network admission standards, rate methodology, step therapy. The DOL fact sheet describes the comparative analysis for each, with six elements [1].
| Element (DOL fact sheet) | What the plan must show | Provider evidence that tests it |
|---|---|---|
| 1. Description of the NQTL | The limitation and the benefits it applies to | Payer policy pages: which therapy codes need authorization, which E/M codes do not |
| 2. Factors and evidentiary standards | What the plan considered in designing the NQTL | Rate methodology letters; written reasons given for denials |
| 3. How the factors are used | The process of applying them | Authorization turnaround and request frequency by benefit type |
| 4. Comparability and stringency, as written | MH/SUD terms no more stringent than M/S terms on paper | Side-by-side of plan documents for therapy versus comparable medical visits |
| 5. Comparability and stringency, in operation | Data showing the NQTL is applied no more stringently in practice | 835 denial rates, allowed-versus-contract variance, appeal overturn rates by benefit type [3] |
| 6. Findings and conclusions | Whether the plan complies | Your dated exhibit, sent with the request for the analysis |
Element fiveThe one a billing office owns. The plan has to prove the limitation is applied no more stringently in operation, and the only operational record of how a plan treated your therapy claims is the 835 remittance you already hold [1].
Four exhibits a payer cannot dispute, because they are built from its own transactions
A
Exhibit A: allowed versus contract by CPT, payer, month
Join the 835 allowed amount on each SVC line to your contracted rate; sum the shortfall where allowed is below contract. Show therapy codes (90791, 90832, 90834, 90837, 90847, 90853) beside the E/M codes the same payer pays your prescribers (99213, 99214).
B
Exhibit B: authorization and medical necessity denials
CO and PI adjustments with CARC 197 (authorization absent), 198 (authorization exceeded), 50 (not deemed medically necessary) and 197-family denials by payer and code. Count requests, denials, units cut and days to decision [3].
C
Exhibit C: network and reimbursement NQTLs
CARC 242 (not provided by network providers) and out-of-network adjustments by clinician and plan, with enrollment dates; plus any rate letter that sets therapy rates by a method not used for medical rates [3].
D
Exhibit D: appeal ledger
Every appeal: date, reason, outcome, dollars, days to decision. An overturn rate that is high for therapy and low for medical visits is itself evidence of stringency in operation.
| Exhibit result | Likely NQTL | Next step |
|---|---|---|
| Therapy allowed consistently below contract; E/M at contract | Reimbursement rate methodology applied differently by benefit type | Underpayment demand on the contract first; parity letter second |
| Authorization required for therapy, not for comparable medical visits | Prior authorization as written | Request the comparative analysis; cite elements 1 and 4 |
| Authorization decisions slower or cut more often for therapy | Prior authorization in operation | Request the analysis; cite element 5; for MA and Medicaid managed care add the 72-hour and 7-day clocks [4] |
| Therapists denied network entry while medical clinicians admitted | Network admission standards | Request the analysis; state network adequacy complaint |
| High appeal overturn on therapy denials | Medical necessity criteria in operation | Request the analysis; pattern letter to the state regulator |
A template, not a result
Our parity underpayment case study is Exhibit A in practice: fourteen locations, two carriers covering about 40% of revenue, 24 months of 835s matched line by line against the rate sheet and against the E/M codes the same carriers paid the group's prescribers.
Average underpayment against contract by code, two carriers, 24 months
From our published case study. The shape is the argument: 19 to 22% on therapy and 1.2% on the medical-management code at the same carrier is hard to call a clerical error, and it is exactly the in-operation comparison element five asks for [1].
19 to 22%below contract90832psychotherapy 30 min
19 to 22%below contract90834psychotherapy 45 min
19 to 22%below contract90837psychotherapy 60 min
1.2%within contract99214E/M, same carriers
Therapy codesMedical management E/M
StepWhat happenedWhen
Demand letterexhibit attached
SentLine-by-line spreadsheet attached, state insurance commissioner copied
Day 0Contract claim first, no parity language yet
Carrier responseboth carriers
ReceivedReconciliation call
Day 21Within 21 days of the letter
Settlementswith interest
OutcomeBoth carriers, with interest and a forward rate correction
Day 92 and 168Carrier A at 92 days, Carrier B at 168 days
Takeaway
Build the exhibit at the CPT level and by month. Annual totals invite a dispute about mix; monthly code-level lines do not.
The same statute through a different door
CMHCs, CCBHCs and SUD programs meet parity under the Medicaid managed care parity rules; the state Medicaid agency is the first regulator, and the record is heavier on authorizations, per-diem codes and carve-outs than on commercial fee schedules. Two features help the file: denials must be made by an individual with appropriate expertise in the enrollee's medical, behavioral health or long-term services and supports needs, and the plans' own prior authorization metrics have been public since March 31, 2026 under CMS-0057-F [5].
| Service line | Typical NQTL | Evidence to capture | Clock or rule |
|---|---|---|---|
| Outpatient therapy and psychiatry | Prior authorization after a visit count; concurrent review | Requests, decisions, units cut, days to decision, by MCO | Standard decisions within 7 calendar days, expedited 72 hours, 2026 rating periods on [5] |
| IOP and partial hospitalization | Medical necessity criteria; per-diem versus per-service payment rules | Denials by criterion; allowed versus the state fee schedule | Denials by an individual with appropriate behavioral health expertise [5] |
| SUD withdrawal management and residential | Day limits per episode or per year; retrospective review | Authorization letters with end conditions; retro denials | Approval must state the date or circumstance under which it ends, impacted payers from 2027 [4] |
| Crisis and peer support | Provider-type and credential limits; place-of-service limits | Enrollment files; CARC 242 and 109 lines by MCO [3] | State plan and MCO contract terms |
| Telehealth and audio-only | Modality limits that do not apply to medical visits | Denied lines by POS and modifier, by MCO | State telehealth policy; compare medical telehealth terms |
One authorization log per MCO
Request time, decision time, units requested, units approved, stated reason.
Carve-out denials to eligibility, same day
CARC 109 is a claim sent to the wrong payer, not a parity file [3].
Reconcile per-diem and encounter payments monthly
Against the state fee schedule, as a commercial group reconciles against contract.
Write to the state Medicaid agency, MCO copied
Not the other way round; keep the dated folder.
Contract first, parity second, regulator third, dated file always
1
The contract claimfirst
Line-level underpayment against the contracted rate, with the 835 allowed amount as proof. Demand the shortfall and interest where state prompt-pay law allows. No parity language yet.
2
The parity patternsecond
Once Exhibit A shows the shortfall is concentrated in MH/SUD codes, add Exhibits B to D and request the plan's comparative analysis for each NQTL involved [1].
3
The regulatorthird
Fully insured plans: the state insurance department. Self-funded ERISA plans: the Department of Labor. Medicaid managed care: the state Medicaid agency and 42 CFR 438 obligations [5].
4
The dated filealways
Each letter, response and remittance in one folder with dates. Parity disputes are decided on the record, not the phone call.
Takeaway
The plan's comparative analysis is theirs to write. Your job is to make the operational record so clear that the analysis cannot honestly reach a different conclusion.
Escalation routes by plan type
The clocks differ by plan type, and the parity pause changes none of them. Once a regulator asks, the plan has 10 business days to produce the comparative analysis, 45 calendar days to respond to an initial noncompliance determination, and 7 business days to notify participants after a final determination [1].
| Plan type | Primary regulator | What you can ask for | Related clocks |
|---|---|---|---|
| Self-funded employer plan (ERISA) | U.S. Department of Labor, EBSA | Participant or representative can request the comparative analysis; EBSA investigates | 10 business days to produce after a regulator request [1] |
| Fully insured commercial plan | State insurance department | Comparative analysis; market conduct complaint; prompt-pay interest under state law | State prompt-pay statutes; HHS encouraged states to mirror the pause but did not require it [2] |
| Medicaid managed care | State Medicaid agency and CMS | Parity compliance under the Medicaid managed care parity rules; authorization decisions within 7 calendar days (rating periods from January 1, 2026) and 72 hours expedited | 42 CFR 438.210(d) [5] |
| Medicare Advantage | CMS | Specific denial reasons since January 1, 2026; published prior authorization metrics since March 31, 2026; Prior Authorization API from January 1, 2027 | CMS-0057-F [4] |
| Non-federal governmental plan | HHS (CMS) | The CAA, 2023 sunset of the self-funded non-federal governmental opt-out is implemented in the 2024 rule | Check the plan's current election status [1] |
The clocks, in days
Plan produces the comparative analysisafter a regulator asks [1]
10 business days22% of the response clock
Plan answers an initial noncompliance finding
45 calendar days100%
Medicaid managed care standard authorization decision2026 rating periods on [5]
7 calendar days16%
Expedited authorization decisionMedicaid managed care and MA
72 hours3 days, 7%
01045 days
Parity clocks on the planAuthorization clocks on the payer
One page, one NQTL, one response date
Short, with the exhibits attached: the plan, the benefit classification, the NQTL, the comparable medical/surgical benefit, the operational data, and the ask. Prior authorization, rate methodology and network standards are separate analyses: one NQTL per letter, response date named and diarized.
| Letter section | What it says |
|---|---|
| Opening | Who you are, which members and plan years, and that you write about treatment limitations applied to mental health and substance use disorder benefits |
| The NQTL | Named in the plan's own words from its policy page or provider manual, with the date and URL |
| The comparison | The medical/surgical benefit in the same classification (outpatient in-network, usually) and how the plan treats it |
| The operational record | A one-paragraph summary of Exhibits A to D with totals, and the exhibits attached |
| The statutory basis | MHPAEA as amended by the CAA, 2021, which the Departments confirmed remains in effect in their May 15, 2025 statement [2] |
| The ask and the clock | Production of the comparative analysis, correction of the pattern, repayment of the shortfall, and a response date |
| Copies | The state regulator for insured plans, with the member complaint route explained to any member who wants to use it |
Takeaway
Never threaten what you will not do. A letter that promises a regulator complaint should be followed by one on the date it names.
A one-time recovery closes a gap; the monthly reconciliation keeps it closed
The practices that recovered in our case study kept a monthly fee-schedule reconciliation with a variance trigger, a quarterly comparison of behavioral health rates against medical/surgical equivalents, and an annual, documented contract review with each carrier.
| Monthly report | Definition | Trigger |
|---|---|---|
| Allowed versus contract by CPT and payer | Sum of (contract minus 835 allowed) where allowed is below contract | Any payer-CPT pair below contract two months running |
| Authorization denial share | CARC 197 plus 198 dollars over total denied dollars, by payer [3] | Rise after a payer policy change |
| Therapy versus E/M variance gap | Average percent below contract for therapy codes minus the same for E/M codes, same payer | Gap widens or stays positive |
| Appeal overturn rate by benefit type | Overturned appeals over appeals decided | Therapy overturn rate materially above medical |
| Network status by clinician and plan | Enrollment effective dates versus first claim date; CARC 242 dollars [3] | Any clinician billing before effective date |
Five events to watch, none of which moves the provider's position
- 1Court decisionA final decision in the ERIC case starts the 18-month nonenforcement tail [2]
- 2Proposed ruleThe Departments may propose rescinding or modifying the 2024 rule [2]
- 3Updated FAQsFAQs Part 45 and other guidance may be revised during reconsideration [2]
- 4State actionStates decide whether to mirror the federal pause for issuers [2]
- 5Jan 1, 2027Prior Authorization API live for MA and Medicaid managed care; denial reasons and metrics already public [4]
The underpayment arithmetic stands on the contract, and the operational record stands on the 835, whichever version of the parity regulation is in force.
Five moves before the next payer letter
Build Exhibit A for your two largest payersAllowed versus contract by CPT and month; the eight-KPI guide shows how to compute the numbers from the 835.
Start the authorization log with time stampsExhibit B needs request and decision dates against the 72-hour and 7-day clocks.
Pick the regulator for each plan type nowBefore the letter, not after; the enforcement timeline tracks the dates that would restart federal enforcement.
Open the dated folderEvery letter, response and remittance, from the first demand.
Use the worksheet, or have it runThe behavioral health RCM toolkit holds the worksheet; for the service side see behavioral health billing services and mental health billing services.
Frequently asked questions
Can a provider still bring a parity claim while the 2024 rule is not enforced?
Yes. The May 15, 2025 statement pauses federal enforcement of the portions of the 2024 rule that are new relative to the 2013 rule. It says MHPAEA's statutory obligations, as amended by the CAA, 2021, continue to have effect, and it does not bind state regulators or change your contract rights.
What is an NQTL comparative analysis and can I ask for it?
It is the plan's written analysis of each nonquantitative treatment limitation (prior authorization, concurrent review, network standards, reimbursement methodology) showing it is applied to MH/SUD benefits no more stringently than to medical/surgical benefits. Participants and their authorized representatives can request it; regulators can require production within 10 business days.
Should I send the parity argument or the underpayment claim first?
The underpayment claim. It is arithmetic against the contracted rate using the 835 allowed amount, it is faster, and the exhibit it produces is the strongest piece of operational evidence for the parity pattern that follows.
Which denial codes belong in a parity evidence file?
CARC 197 and 198 (authorization absent or exceeded), 50 (not medically necessary), 242 (not provided by network providers) and out-of-network adjustments, each by payer, code and benefit type, alongside allowed-versus-contract variance from the AMT and SVC segments.
Do the Medicaid managed care authorization clocks help a parity argument?
They help the operational record. For rating periods starting on or after January 1, 2026, 42 CFR 438.210 caps standard authorization decisions at 7 calendar days and expedited decisions at 72 hours. Slower decisions on therapy than on medical services, documented with time stamps, are evidence of stringency in operation.
- DOL EBSA fact sheet: Final Rules under the Mental Health Parity and Addiction Equity Act (September 2024)
- Departments of Labor, HHS and the Treasury: Statement Regarding Enforcement of the Final Rule on Requirements Related to MHPAEA (May 15, 2025)
- X12: Claim Adjustment Reason Codes (CARC) and Claim Adjustment Group Codes
- CMS fact sheet: Interoperability and Prior Authorization Final Rule, CMS-0057-F (January 17, 2024)
- 42 CFR 438.210, Coverage and authorization of services (Medicaid managed care), govinfo.gov
Checked October 25, 2026. Confirm against the source; items marked proposed may change in the final rule.
Suspect a payer is applying limits to therapy it does not apply to medical care?
We build Exhibits A to D from your 835s, send the contract claim first, and prepare the comparative analysis request with the regulator route per plan type.