Single case agreements for behavioral health: how they work and why they get denied

Payers do not owe every out-of-network provider an SCA. Lucet, a behavioral health manager, puts it plainly: an SCA is not needed if the member's policy already covers the service, and it might be available when services are not covered because of network or benefit limits and the treatment is medically necessary. The common reasons facilities ask are:

• No in-network option. No contracted program at that level of care has an opening within a reasonable distance and time.
• Specialized care. The patient needs a program the network does not offer, such as eating disorder residential or a co-occurring program.
• Continuity of care. The patient is already in treatment with you and a move would put the episode at risk.
• Plan type. The plan (often an HMO or EPO) has no out-of-network benefit, so without an agreement the claim pays nothing.

Payers treat these requests as a clinical question. Health Net's behavioral health position statement says a Clinical Manager or Medical Director decides whether the treatment is medically necessary and whether a contracted provider in the member's area could provide it. If the request is about convenience or preference, Health Net issues an administrative denial. If the clinical request is denied, the member has the full appeal process.

The request usually comes from utilization review or admissions, with billing weighing in on the rate. It goes to a payer care manager or the behavioral health vendor named on the member card. Lucet tells providers to call the number on the back of the card to find out if an SCA is an option. Ask who handles SCAs for that plan and whether it has a request form. There is no universal single case agreement form.

• Patient and plan identifiers, and whether the plan is fully insured or self-funded (ask; it changes which rules apply)
• Level of care requested and the criteria you used (for example The ASAM Criteria or LOCUS), with the clinical summary behind it
• Why an in-network provider cannot meet the need: who you or the payer checked, when, and what they said (no bed, no program, wait too long, too far)
• Start date, expected length of stay, and the number of days or units you are asking for
• Billing codes for each level: for example revenue code 1001 or 1002 for residential, 0912 or 0913 with H0035 for PHP, and 0905 with S9480 or 0906 for IOP. Some payers want H0018 or H0019 on residential lines
• Proposed rate and basis: per diem by level of care, a percent of billed charges, or another method, and whether it is all-inclusive
• Step-down plan, so PHP and IOP are covered by the same agreement or a planned amendment

The revenue code guide has the full code table and the pairings payers publish. Use the codes you will actually bill. An agreement written for one code and billed under another is a common reason an SCA claim pays wrong.

A phone approval is not an agreement your billing team can enforce. Before the claim goes out, you want a signed or written agreement that shows:

• The SCA or reference number, and the name of the person who approved it
• The patient, the levels of care, and the revenue and HCPCS codes it covers
• Covered dates and the number of days or units, and how extensions work
• The rate, the rate basis, and whether it is all-inclusive or lists carve-outs
• How it ties to the authorization: the auth number, and whether concurrent review still applies
• Billing instructions: claim form, address, and what to attach or reference

Billing instructions matter. Health Net, for example, requires paper claims with a copy of the SCA attached to receive the agreed rate, says claims without the SCA are incomplete and may be denied, and does not support electronic submission for these claims. Other payers set different rules, so read the agreement.

The most expensive pattern is quiet: the claim pays, but at the plan's usual out-of-network allowed amount instead of the SCA rate. Nothing denies, so no one looks. Compare every SCA remittance to the agreement, line by line.

1. 1Pull the written agreement, the authorization, the claim and the remittance.
2. 2If the claim itself was wrong (missing SCA number, wrong codes, wrong dates), send a corrected claim. That is not an appeal.
3. 3If the claim was right and the payment was not, file the payer's reconsideration or payment dispute. Attach the agreement, quote the rate and covered dates, and show the math: agreed amount, paid amount, balance.
4. 4If that fails, file a formal appeal at the next level. Keep the payer's deadlines; the medical necessity appeal guide lists published windows for major payers.
5. 5If days were denied as not medically necessary, treat that part as a clinical appeal, separate from the rate dispute.

Do not bill the patient the difference between the SCA rate and what the payer paid without checking the agreement and your state's balance billing rules first. The agreement may limit what the patient can be charged.

California law gives facilities a strong argument for an SCA. Health and Safety Code section 1374.72, as amended by SB 855 in 2020, says that if medically necessary mental health or substance use disorder treatment is not available in network within the geographic and timely access standards, the plan shall arrange coverage to ensure delivery of medically necessary out-of-network services and any medically necessary follow-up services. The enrollee pays no more than in-network cost sharing. Insurance Code section 10144.5 sets the same rule for insurers regulated by the Department of Insurance.

The timely access standards are in Health and Safety Code section 1367.03. They include urgent appointments within 48 hours when no prior authorization is required and 96 hours when it is, and non-urgent appointments with a non-physician mental health or SUD provider within 10 business days. Section 1367.03 also says that when medically necessary MH or SUD treatment is not available in network within these standards, the plan must arrange coverage outside the network under section 1374.72.

• Document network gaps when you request the SCA: which in-network programs were called, when, and the earliest opening they offered.
• Section 1374.72 does not apply to Medi-Cal managed care contracts.
• Self-funded employer plans are generally governed by federal law, not these state rules. Ask the payer whether the plan is fully insured.

• Verify benefits and confirm there is no in-network option at this level of care
• Call the number on the member card and ask for the SCA contact and form
• Send the request with clinical justification, network gap evidence, codes, dates and proposed rate
• Get the written agreement with reference number, rate basis, dates, units and codes
• Load the agreement terms into your billing system before the first claim
• Track the authorization and request extensions before the end date
• Bill exactly as the agreement says, with the reference or attachment the payer requires
• Compare each remittance to the SCA rate and dispute any shortfall

Have an SCA claim that denied or paid short? Look up the codes in the denial code tool, or see how denial recovery and a denial audit work.