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SCA Quick Reference
Single Case Agreement cheat sheet — for patients, families, and providers — AvoidRehab Editorial Team • Last reviewed June 2026
Key correction most guides get wrong: A behavioral health case manager handles care coordination, not SCA authorization. The department you need is Utilization Management (UM) or Clinical Review. Ask for it by name when you call.
Patient / Family Checklist
- Call the BH line on your card. Ask for Utilization Management or behavioral health clinical review — not general member services.
- Ask two questions upfront:
- Do I have out-of-network benefits?
- Can I request an OON authorization / single case agreement if no adequate in-network option is available?
- Request the in-network provider list for your specific needed service (residential SUD, DBT IOP, dual-diagnosis PHP, etc.). Write down the date you received it.
- Call every provider on the list. For each call, document: date, provider name, rep name, and the specific reason they cannot meet your needs (full, no availability, wrong specialty, excessive wait, no language services, etc.).
- Obtain a letter of medical necessity from a licensed clinician: diagnosis, recommended level of care, clinical rationale for the specific OON provider, and a statement that no in-network equivalent is available or appropriate.
- Have your chosen program call UM to request OON authorization. Programs with SCA experience are faster.
- Follow up every 5 business days if no update. Document every call.
- Get the SCA in writing before starting treatment. Confirm CPT codes, authorized dates, and cost-share terms.
If denied: appeal using your call log + MHPAEA network adequacy argument. See the full appeal guide.
Provider / Program Checklist
- Verify member eligibility and benefits before initiating: is there an OON benefit? HMO vs. PPO? Which BH vendor manages the plan?
- Call the BH line on the member's ID card. Ask for Utilization Management / Clinical Review. Request OON authorization citing at least one qualifying criterion (no adequate network coverage for this modality, specialty, or geography).
- Submit clinical documentation: diagnosis codes (ICD-10), CPT codes for requested services, letter of medical necessity, treatment plan, and documentation that no adequate INN option exists.
- After UM approves OON authorization, the insurer's SCA team contacts you. At Carelon, expect the SCA document within 10 business days. Sign and return electronically within the 10-calendar-day window.
- Rate negotiation: Carelon and Optum load internal fee schedules — these are minimally negotiable. Smaller commercial plans often accept a counter at 85–90% of billed charges. Know your floor before accepting.
- Confirm rate, CPT coverage, and authorized dates match the signed SCA before billing.
- For extensions: call the same BH line, request a date extension on the existing OON auth. Existing rates apply; no new SCA required at Carelon.
- Claim submission: Carelon uses Availity (payer ID on the member ID card). Submit within 90 days of DOS or discharge.
If provider refuses Carelon’s rate: Carelon loads an “Unsecured SCA” at their standard rate anyway. Weigh this before rejecting their offer.
Script: What to Say on the First Call
When you reach the behavioral health line:
Opening: “I need to request an out-of-network authorization and single case agreement for behavioral health treatment. I’d like to speak with Utilization Management or the behavioral health clinical review team.”
If they push back on OON: “I have contacted every in-network provider on the list provided and documented why none can meet my clinical needs. I’m requesting this under MHPAEA network adequacy requirements.”
If told “case manager will call you”: “I understand, but the SCA request needs to go through Utilization Management for clinical review. Can you connect me or note on the record that I’m requesting OON authorization, not care coordination?”
If they send a provider list: “I will contact each provider and document the results. I’ll call back within [X] days to report my findings and request the OON authorization proceed.”
Documents to Have Ready
- Insurance card (front and back — has the BH line number and payer ID)
- Provider call log (date, provider name, rep, outcome for each INN provider contacted)
- Letter of medical necessity from a licensed clinician (see checklist)
- ICD-10 diagnosis code(s)
- CPT codes for the services being requested (your provider can supply these)
- OON provider’s NPI number and Tax ID
- Treatment plan or intake assessment from the OON provider
- Prior treatment records if continuity of care is an argument
- Notes from all prior calls with the insurer (dates, rep IDs or names, what was said)
Keep everything in a single folder. You may be asked for the same documents multiple times by different departments.
Major Insurer Contacts & SCA Notes
| Insurer / BH Vendor | Who to Call | Phone | SCA Department | Key Notes |
|---|---|---|---|---|
| Carelon Behavioral Health (Anthem / BCBS Anthem-affiliated plans) |
Providers: National Provider Services Members: number on ID card |
1-800-397-1630 (providers) ID card (members) |
Internal SCA Team post-UM approval | UM = Clinical Care Manager (CCM). SCA team has 10 business-day processing window. Medicaid/Medicare: no SCA needed, paid at allowable rates. Rate minimally negotiable — standard fee schedule loaded unilaterally if refused. |
| Optum Behavioral Health (UnitedHealthcare commercial & MA) |
Providers: ProviderExpress portal Members: UHC member line on ID card |
Portal: providerexpress.com ID card (members) |
Network contracting post-UM approval | Verify OON benefit exists first — some UHC commercial products have eliminated OON benefits. UM handles clinical auth; internal OON/contracting team handles SCA. |
| Aetna Behavioral Health (CVS-owned) |
Providers: BH provider line Members: member services on ID card |
1-800-872-3862 (BH providers) ID card (members) |
BH UM / Clinical Review first contact | Request OON auth through BH UM, not general member services. Fined for parity violations (April 2026). OON authorization required before SCA negotiation. |
| Cigna Behavioral Health | Providers: BH provider line Members: member line on ID card |
1-800-244-6224 (BH providers) ID card (members) |
BH UM / prior auth team first contact | All higher levels of care require prior authorization. Request OON auth through UM. Fined for parity violations (April 2026). |
| BCBS (non-Anthem) BCBSMA, Horizon BCBSNJ, BCBSTX, HCSC, etc. |
Members and providers: number on ID card | ID card | BH UM / OON team varies by plan | Each plan is independent. BCBSMA has a published OON Request Form on provider.bluecrossma.com. For all others: call member services, ask specifically for behavioral health UM or the OON authorization team. |
| Medicaid managed care | Members: number on ID card Providers: plan-specific |
ID card | BH UM plan-specific | No SCA document typically required at Carelon-managed Medicaid plans — OON auth approved clinically and paid at Medicaid allowable rates. Other Medicaid MCOs vary. Ask the plan’s BH line specifically about OON authorization. |
| Traditional Medicare | — | — | — | SCAs not available. OON follows standard Medicare rules. |
| Medicare Advantage | Members: number on ID card | ID card | BH UM plan-specific | “Gap exceptions” or “network exceptions” function similarly to SCAs but are harder to obtain. Ask BH UM line specifically. |
Common Roadblocks and Responses
| What the insurer says | What it means | Your response |
|---|---|---|
| “We have in-network providers available.” | They have names in a directory. May not mean those providers are available, accepting new patients, or clinically appropriate. | Request the list. Call every provider. Document outcomes. Report back. This defeats most denials. |
| “Your case manager will follow up.” | General case management, not UM. SCA won’t advance this way. | “I need this routed to Utilization Management for OON authorization, not care coordination. Can you transfer me or flag the request?” |
| “You don’t have out-of-network benefits.” | True for HMO plans. Does not automatically mean no SCA is possible. | “I understand. Can an SCA or OON authorization be approved as a network adequacy exception when no adequate in-network provider is available?” |
| “The rate we offer is non-negotiable.” | Common at Carelon, Optum. Their fee schedules are internal and minimally flexible. | Provider decision. If plan will load standard rate regardless, the provider should weigh accepting vs. declining. Unsigned SCA = standard rate loaded unilaterally at Carelon. |
| No response after UM approval. | SCA team backlog. Standard at Carelon is 10 business days, can be longer. | Call back at day 10. Request escalation if clinical urgency. Document every call. |
| “This is a denial.” | OON authorization was denied by UM. | File an internal appeal using MHPAEA network adequacy argument + provider call log + letter of medical necessity. Request external review if internal appeal fails. See appeal guide. |
This reference is for educational purposes. Insurance processes vary by plan year, state, and product type. Verify details with your specific plan before relying on any number or process listed here. Nothing on this page constitutes legal or medical advice.
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