Medical-necessity criteria and claim-file request letter

How do I use the criteria request letter generator?

Choose what you want (criteria, claim file or both), the plan type and who is asking, then add the plan name, the service and the denial date. The letter updates as you type. Leave identifiers blank: they stay as bracketed placeholders you fill in after downloading, so no patient data goes into the browser.

1. 01Pick Criteria and the full claim file unless you already have one of them. Asking for both in one letter saves a round trip.
2. 02Pick the plan type. It changes the regulation the letter cites; a Medicaid plan answers to 42 CFR Part 438, not ERISA.
3. 03Pick who is asking. A provider asking on the patient's behalf should enclose the patient's signed authorization.
4. 04Add the plan name, the service or level of care and the date of the denial.
5. 05Copy the text, download it as .txt, or print it. Fill in the bracketed blanks outside the browser, sign, and send by fax, certified mail or the portal so you have proof of the date.

What does the plan have to give you about its medical-necessity criteria?

For mental-health and substance-use benefits, the plan administrator or insurer must make its medical-necessity criteria available on request to any current or potential participant, beneficiary or contracting provider. It must also give the reason for any denial. That covers the criteria set the reviewer actually applied, not a marketing summary of it.

The rule is the parity regulation's disclosure paragraph: 29 CFR 2590.712(d)(1) for ERISA plans, and the matching 45 CFR 146.136(d)(1) for insurers, which 45 CFR 147.160 applies to individual coverage. Medicaid managed care has its own version at 42 CFR 438.915(a).

Plans often use licensed criteria sets such as ASAM, LOCUS/CALOCUS, InterQual or MCG, or a vendor's own guideline. The Department of Labor's September 2026 enforcement bulletin (FAB 2026-03) says nothing prohibits proprietary guidelines, but plans must make them available to participants and beneficiaries on request. Ask for the edition and the specific criteria the reviewer found unmet.

For ERISA plans, 29 CFR 2590.712(d)(3) adds a pointer: ERISA's document-disclosure rules require plan instruments, including the criteria and the processes, strategies and evidentiary standards used to apply limits to both mental-health and medical/surgical benefits, within 30 days of a written request.

What is in the claim file, and can I get it free?

Yes. ERISA plans must give claimants, on request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim. Relevant includes anything relied on, anything submitted, considered or generated, and any policy or guidance about the denied treatment for the diagnosis, whether or not it was relied on.

The access rule is 29 CFR 2560.503-1(h)(2)(iii) and the definition of relevant is paragraph (m)(8). The plan must also identify the medical experts whose advice it obtained, whether or not it relied on them ((h)(3)(iv)). For non-grandfathered plans, any new evidence or new rationale must be sent to you free, before the final appeal decision, with time to respond (29 CFR 2590.715-2719(b)(2)(ii)(C)).

Medicaid managed care plans must give the enrollee and representative the case file, including medical records and any new evidence, free of charge and sufficiently in advance of the appeal deadline (42 CFR 438.406(b)(5)). Medicare Advantage plans provide the case file on request, and CMS guidance lets them charge a reasonable copying and mailing fee, which they should estimate up front.

Who can request the criteria and the claim file?

The member can always ask. For criteria, contracting providers can ask in their own right under the parity rule. For the claim file, a provider usually asks as the member's authorized representative, with a signed authorization. On an urgent ERISA claim, a health care professional who knows the condition can act as representative without one.

ERISA plans may set reasonable procedures for confirming who is an authorized representative (29 CFR 2560.503-1(b)(4)), so use the plan's own form if it has one. In Medicaid managed care, a provider can appeal for the enrollee only where state law allows and with the enrollee's written consent.

How fast does the plan have to respond?

The claims rule sets no fixed number of days for the claim file, so ask early and say you need it before the appeal deadline. For ERISA plan instruments, including the criteria, a written request to the plan administrator triggers ERISA's 30-day rule, and a court can impose up to $110 a day for failure to comply.

The 30-day rule and the penalty come from ERISA section 502(c)(1) and 29 CFR 2575.502c-1. Send the request to the plan administrator named in the Summary Plan Description, not only to the claims vendor. A request does not pause the appeal clock, so file the appeal on time even if the documents are late, and say in the appeal that they were requested and not received.

What can I do if the plan doesn't respond?

Follow up in writing with the date of the first request and proof of delivery. Then raise it with the regulator for the plan type: the Department of Labor's EBSA for employer plans, the state insurance department for insured coverage, and the state Medicaid agency for Medicaid plans. Note the missing documents in the appeal itself.

• Employer plans: submit an inquiry or complaint through Ask EBSA or call 1-866-444-3272.
• Insured plans: find the state insurance department in the NAIC directory.
• State and local government employer plans: CMS runs a parity help line (1-877-267-2323 extension 6-1565).
• Medicaid managed care: raise it in the plan appeal and, after an upheld appeal, at the state fair hearing.