Understanding Insurance and Single Case Agreements
By Mary Attridge, CMHC, ATR-BC, ATCS, EMDRIA-CIT
Do you have a specific provider that you’d like to see and it turns out that they are not in network with your insurance? It can feel like you’ve reached a dead end however, all hope is not lost. Single Case Agreements or SCAs are a way that you may be able to access your health insurance benefit, even when the provider you wish to see is not in their network.
Insurances contract with different providers in order to secure rates that are typically reduced from the provider’s standard fees. Think how your membership at Costco gets you a lower price on some of your favorite brands! They negotiate these in exchange for providing bulk orders from the manufacturer and the manufacturer increases their market share with the engagement of the members at Costco. Insurance works very similarly.
Sometimes, though, an insurance company either does not have enough providers credentialed to serve their members or they don’t work with the provider you have an existing relationship with if your insurance carrier changes.
But good news: you still have options.
You can request a Superbill and submit this to your insurance for out of network reimbursement.
You can request a Single Case Agreement or a Network Exception and have it based on your “existing provider relationship,” and/or “a network deficiency.”
In the first case, we will prepare a Superbill, which has all the necessary information for your insurance to process your claim. You will submit this then to your insurance and handle things from there. They will determine the claim’s eligibility for coverage, based on your plan, and rule accordingly. You can contact your member services ahead of time to ask about what you can expect for coverage. Sometimes you’ll have a separate out of network deductible to meet, or a different copay/coinsurance amount. Just let them know you are looking for information about your “out of network outpatient mental health” coverage.
In the second case, you will initiate a conversation with our billing team and your insurance. We will do our best to negotiate an acceptable rate of reimbursement with them and sign an agreement that will extend no later than December 31st of the next calendar year. This kind of agreement is typically renewable on an annual basis. If they accept and your provider is seen as an exception, we can then submit your claims on your behalf and it will work much like an in network visit.
We understanding that navigating the world of health insurance is often confusing and frustrating, and we hope to make the process as easy as possible! Feel free to reach out any time with questions or concerns and our billing team is happy to help.
