Same plan. Same telehealth. Opposite answer.
This is a fully anonymized worked example. One member, one plan. The plan paid out-of-network telehealth claims for medical care, then denied structurally identical out-of-network telehealth claims for mental health. Same classification, opposite treatment based only on the diagnosis — a nonquantitative treatment limitation applied more restrictively to mental-health benefits.
No real PHI. The provider names, claim numbers, and amounts are fictional composites built to show the detection.
| Claim | Date | Dx | Type | Paid |
|---|---|---|---|---|
| Q100001306160075 | 03/04/2025 | M54.50 | Medical | $232.87 |
| Q100001306477504 | 03/18/2025 | M54.50 | Medical | $273.81 |
| E300001310285497 | 03/06/2025 | F41.1 | Mental health | $0.00 |
| E300001310288844 | 03/20/2025 | F33.1 | Mental health | $0.00 |
This names the specific paid medical comparator claim numbers and the denied mental-health claim numbers, with the amounts and the regulatory citation. Review before you send it to your carrier.
RE: Mental Health Parity (MHPAEA) — request for the plan's written comparative analysis and reprocessing of denied mental-health out-of-network telehealth claims. Within the out-of-network telehealth classification, the plan PAID the following medical/surgical claim(s): - Q100001306160075 — DOS 03/04/2025 — dx M54.50 — paid $232.87 - Q100001306477504 — DOS 03/18/2025 — dx M54.50 — paid $273.81 Within the SAME out-of-network telehealth classification, the plan DENIED (paid $0.00) the following mental-health claim(s): - E300001310285497 — DOS 03/06/2025 — dx F41.1 — paid $0.00 - E300001310288844 — DOS 03/20/2025 — dx F33.1 — paid $0.00 These claims share the same structure — out-of-network telehealth — and were treated oppositely based solely on whether the diagnosis was medical/surgical or mental health. 29 CFR 2590.712 — under the Mental Health Parity and Addiction Equity Act (MHPAEA), a group health plan may not apply any treatment limitation to mental health or substance use disorder benefits that is more restrictive than the predominant treatment limitation applied to substantially all medical/surgical benefits in the same classification. Paying a medical/surgical out-of-network telehealth claim while denying a structurally identical mental-health out-of-network telehealth claim is a nonquantitative treatment limitation (NQTL) applied more restrictively to mental-health benefits. Please provide, in writing: (1) the plan's comparative analysis demonstrating that the nonquantitative treatment limitation applied to the denied mental-health telehealth claims is no more restrictive than the limitation applied to medical/surgical telehealth claims in the same classification; and (2) reprocessing of the denied mental-health claims listed above. Please provide a reference number for this request.
The engine does not know the clinical details. It works from the claims you upload — the diagnosis code (F-codes are mental health), the network status, the place of service (telehealth), and the paid amount. When there is no paid medical comparator or no denied mental-health claim in the same out-of-network telehealth classification, it says so plainly and asserts nothing.
Check your own claims →