Sample Forms to Request Documentation Concerning Treatment Limitations

Sample form from the DOL to request documentation from an employer sponsored health plan or an insurer concerning treatment limitation.

Document Excerpt
Background: This is a tool to help you request information from your employer-sponsored health plan or your insurer regarding limitations that may affect your access to mental health or substance use disorder benefits. You can use this form to request general information about treatment limitations or specific information about limitations that may have resulted in denial of your benefits. An example of a request for general information might be a request for the plan’s preauthorization policies for medical/surgical and mental health treatments. An example of a request for specific information related to a denial of benefits based on a failure to show medical necessity might be a request for the internal medical necessity guidelines used to deny your claim. Your plan or insurer is required by law to provide you this information in certain instances, and the information will help you determine if the coverage you are receiving complies with the law.


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