A single case agreement is an agreement that an insurance company will use with a healthcare provider not in their network as an in-network provider for a specific case and a specific episode of treatment. This often occurs when an in-network provider is not available due to proximity or specialty. Both the insurance company and Pasadena Villa Psychiatric Residential Treatment Centers will need to agree to the rates and terms, and the agreement shall specify how to submit claims, obtain authorizations for continued care, and other important details.
Single case agreements may be initiated in two ways:
1. The family or payer requests that we consider one. This primarily occurs early in the intake phase with our Admissions Counselors.
2. The Admissions team identifies someone in need of services who has good insurance, but simply cannot afford to pay the out of pocket costs for our services, in hopes of being reimbursed later.
The Admissions staff can initiate this process if:
1. The person seeking treatment is clinically viable and looks like a good candidate for our programs
2. Insurance is verified
3. There is a good history of working with the insurer in terms of UR and payment
Facilitating a SCA requires teamwork and frequent communication between multiple parties. The process is generally as follows:
1. SCA is brought up for consideration
2. Insurance is verified
3. Intake discusses verification of benefits and if we have worked with the insurance company before (items such as: history of claims, utilization review, access, payments, and so on)
4. If signs indicate good coverage and a positive history with the insurance company, the Intake staff sends the clinical information to our Utilization Review department for review.
5. In these situations, there MUST be an authorization prior to admission from the insurance company. We cannot admit without an authorization for initial treatment.
6. Intake will notify the family and/or insurance company that we would like to entertain a SCA, and the insurance company will then send a proposed SCA to Intake, specifying the proposed rate, as well as other items like authorizations and claims submission.
7. Generally, we will charge co-pays and deductibles, but not invoice the client at all during treatment, only submitting claims to the insurance company.
8. This agreement will go before the Governing Board for final review and approval.
9. The SCA is for one client and one episode of treatment. This means that Pasadena Villa Psychiatric Residential Treatment Centers is not bound by the terms of the SCA for future cases that may arise.