42 CFR § 438.915 - Availability of information.

---
identifier: "/us/cfr/t42/s438.915"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 438.915 - Availability of information."
title_number: 42
title_name: "Public Health"
section_number: "438.915"
section_name: "Availability of information."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "C"
subchapter_name: "MEDICAL ASSISTANCE PROGRAMS"
part_number: "438"
part_name: "MANAGED CARE"
positive_law: false
currency: "2026-03-24"
last_updated: "2026-03-24"
format_version: "1.1.0"
generator: "[email protected]"
authority: "42 U.S.C. 1302."
regulatory_source: "67 FR 41095, June 14, 2002, unless otherwise noted."
cfr_part: "438"
---


# 438.915 Availability of information.

(a) *Criteria for medical necessity determinations.* The criteria for medical necessity determinations, made by a MCO or by a PIHP or PAHP providing services to an MCO enrollee, for mental health or substance use disorder benefits must be made available by the MCO, PIHP, or PAHP administrator to any enrollee, potential enrollee, or contracting provider upon request. MCOs, PIHPs, and PAHPs operating in compliance with § 438.236(c) will be deemed compliant with the requirements in this paragraph (a).

(b) *Reason for any denial.* The reason for any denial by a MCO, PIHP, or PAHP of reimbursement or payment for services for mental health or substance use disorder benefits in the case of any enrollee must be made available by the MCO, PIHP, or PAHP administrator to the enrollee.

(c) *Provisions of other law.* Compliance with the disclosure requirements in paragraphs (a) and (b) of this section is not determinative of compliance with any other provision of applicable Federal or State law.