Physician-authored review of a 20–50 claim sample assessing whether the plan's medical necessity criteria were applied in a clinically defensible and consistent manner — framed for ERISA fiduciary defense or DOL audit response.
How the claim sample was selected, what was included and excluded, what denial types and condition categories are represented, and what criteria sets are assessed.
Grouping of sampled denials by type, criteria cited, and condition category — establishing the pattern baseline before mismatch analysis begins.
Where the denial rationale does not align with the criteria the plan claims to apply — specific examples showing "criteria cited in denial letter" vs. "criteria actually applicable per plan's own clinical policy."
Per denial category: Defensible / Questionable / Indefensible — with physician narrative explaining the clinical basis for each classification.
Physician summary of the systematic findings — whether the pattern reflects appropriate clinical judgment, systematic over-restriction, inconsistent application, or criteria misapplication across the sample.
Written physician interpretation of the pattern findings — the section a pure actuarial or compliance analyst cannot produce. Framed for submission to counsel, inclusion in a DOL response, or use in fiduciary defense proceedings.
You represent an employer plan sponsor facing a DOL audit or member class action and need a physician to assess whether the TPA's denial decisions were clinically defensible.
A self-insured plan client wants pre-litigation risk assessment before exposure becomes litigation — a physician audit of denial patterns before the DOL asks for the same records.
You are defending a TPA or ASO administrator facing fiduciary breach claims and need independent physician documentation that criteria application was clinically sound.
A regional carrier is facing an MHPAEA enforcement action and the behavioral health denial pattern — not just the written criteria — is under scrutiny.
Required inputs from client: De-identified denial letters, clinical criteria cited in denials, plan's clinical policy manual, member clinical records if available.
This is not: a re-adjudication of individual claims, a recommendation to overturn or uphold specific denials, or a legal opinion on ERISA fiduciary breach. That conclusion belongs to retained counsel.
Abbreviated 10-claim specimen with fictional data. Criteria mismatch table, defensibility grading, pattern identification — methodology demonstrated.
The MHPAEA Parity Review examines how the plan's written criteria compare across BH and M/S — the criteria design question, not the application pattern question.
Send only the plan type, denial sample size, and general scope first — no documents required to start.