TLDR
A single case agreement (SCA) is a one-time contract between your insurance plan and an out-of-network provider, covering one patient for one episode of care at a negotiated rate. The result: you pay in-network cost-sharing instead of the full out-of-network exposure. SCAs are available when no adequate in-network option exists. The process starts with a call to the behavioral health line on your insurance card, where you will reach a utilization management (UM) or clinical reviewer. A general case manager handles care coordination, not SCA authorization. After UM approves the out-of-network authorization, a separate internal SCA or network contracting team handles the rate document with the provider. The patient and family’s primary job is building a documented case that in-network alternatives are inadequate. The provider does the rate negotiation. Timeline is typically 10 to 15 business days end-to-end for plans like Carelon; longer for some commercial plans. See the SCA cheat sheet for a one-page reference.
What a single case agreement is
A single case agreement is a negotiated contract between one insurance plan and one out-of-network provider, covering one patient for one episode of care. When that episode ends, the agreement ends.
Under an SCA, the patient pays only their standard in-network copayment or cost-sharing. The insurer covers the remainder at a rate determined through the agreement. Without an SCA, a patient using out-of-network benefits typically faces a separate, higher out-of-network deductible (often $2,000 to $5,000 or more), higher coinsurance, and in many plans no out-of-pocket protection equivalent to the in-network maximum. For patients with no out-of-network benefits at all, an SCA may be the only path to any coverage.
SCAs are not a workaround. They are a formal mechanism that major insurers publish policies for. Carelon Behavioral Health (the behavioral health subsidiary managing benefits for most Anthem and BCBS Anthem-affiliated plans nationally) publishes its SCA and OON Reimbursement Policy as a numbered procedure: NM 306.10, last revised March 2025. Optum (UnitedHealthcare’s behavioral health arm), Aetna, and Cigna all have analogous internal processes.
Who actually handles SCAs inside an insurance plan
This is where the most common misunderstanding occurs, and where the clinician’s experience that case managers often do not handle SCAs is correct.
Insurance companies have distinct departments that serve different functions:
Member Services / Behavioral Health Line: The first point of contact when you call the number on your card. They route calls but do not make clinical or SCA decisions.
Utilization Management (UM) / Clinical Care Management (CCM): The department that reviews requests for out-of-network authorization. They apply clinical criteria to determine whether no adequate in-network option exists and whether the requested care is medically necessary. This is the department you need to reach to initiate an SCA. At Carelon, this function is called the Clinical Care Manager (CCM) team.
SCA Team / Network Contracting: After UM approves the out-of-network authorization, an internal SCA team drafts the SCA document and loads the reimbursement rates. At Carelon, this team operates separately from clinical review and has its own 10-business-day processing window. The provider receives the SCA electronically for signature. The patient does not interact with this team directly.
Behavioral Health Case Manager: A care coordination role. Helps members find providers, navigate transitions between levels of care, and coordinate ongoing treatment. Case managers are not the SCA approvers and typically cannot authorize out-of-network exceptions. Asking a case manager to “approve an SCA” will usually produce a referral back to the member services line.
Provider Relations: Handles network credentialing and in-network contracting questions. Not the SCA path for a patient.
The practical implication: when you call, ask to speak with Utilization Management or Clinical Review for behavioral health, not a general case manager. If the representative routes you to a case manager who is unfamiliar with OON authorization, ask specifically for UM or the behavioral health clinical team.
The network adequacy problem
SCAs in behavioral health exist at the volume they do because behavioral health network adequacy is genuinely poor. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans to apply the same treatment limitations to behavioral health benefits as to comparable medical and surgical benefits, including network adequacy. In practice, enforcement has been inconsistent.
Federal data from the Department of Labor’s 2024 Report to Congress under MHPAEA found that SUD claims are denied at rates far exceeding comparable medical/surgical claims. Virginia’s 2025 Mental Health Parity Report found SUD claims denied at 25.6 percent versus 17.9 percent for medical/surgical. In April 2026, Aetna, Cigna, and UnitedHealthcare were fined by state regulators for mental health parity violations.
Under MHPAEA 2024 final rules (effective January 1, 2025 for most group plans), plans must take corrective action when data shows material differences in out-of-network utilization for behavioral health versus medical care. A documented failure of in-network adequacy is both a clinical argument and a legal one.
When you qualify
Insurers approve SCAs when the patient can document that no in-network provider adequately meets their clinical needs. Carelon’s published criteria (NM 306.10) require at least one of the following to apply:
- No network resources for required covered services within access standards of the member’s residence
- Network facilities are at capacity or practitioners cannot accommodate new patients
- Clinical or service needs (specialty, language, cultural competency, gender) cannot be met by available network resources
- Member preferences are relevant to treatment outcome and cannot be met in-network
- Necessary continuity of care with an out-of-network provider with treatment history
- Available network resources have stated they cannot meet the member’s service needs
- A network facility is not contracted for a specific required treatment modality
- The member is a full-time student outside the geographic area of the plan’s network
- Confidentiality concerns (e.g., the member is an employee of the plan)
Note: at Carelon, SCAs are not issued for Medicaid members (reimbursed at Medicaid allowable rates without SCA), Medicare members (reimbursed at Medicare allowable rates without SCA), emergency inpatient admissions, continuity of care cases when a member is simply new to a health plan, or situations where adequate in-network providers exist.
The step-by-step process
Step 1: Call the behavioral health line and reach Utilization Management
Call the behavioral health number on the back of your insurance card. If your plan uses a separate behavioral health vendor (common for Anthem/BCBS plans, where the number routes to Carelon; UHC plans, where it routes to Optum; Aetna; Cigna), you will be connected directly to that vendor.
Say: “I need to request out-of-network authorization and a single case agreement for behavioral health treatment. I’d like to speak with Utilization Management or the clinical review team.”
Do not rely on a general case manager to advance this request. Ask specifically for UM.
Step 2: Request the in-network provider list and note the date
Ask for a complete list of in-network providers offering the specific service you need. Write down the date you received it.
Step 3: Contact every provider on the list and document the results
Call each provider. For each call, document: date, provider name, who you spoke with, and the specific reason this provider cannot meet your needs (not accepting new patients, no availability within 30 days, no relevant specialty, no capacity for co-occurring disorders, no services in your language, etc.).
This documentation is the most important evidence in an SCA request. When the insurer counters by saying “adequate in-network providers are available,” your documented call log is the response. If you have not called the providers on the list, the insurer can legitimately deny. If you have, and you have documented specific reasons for each, the denial is much harder to sustain.
Step 4: Get a letter of medical necessity
A letter from a licensed clinician (prescriber, outpatient therapist, or the admitting program’s clinical director) should include: diagnosis, recommended level of care, clinical rationale for the specific program or provider, and an explicit statement that no adequate in-network equivalent is available. Specificity matters. “No in-network DBT-certified program within 50 miles” is more useful than “patient prefers this provider.”
Step 5: The provider calls UM to initiate the OON authorization
Once you have a specific program willing to accept an SCA, have their admissions or billing team call the same behavioral health line. They request OON authorization from UM. The clinical review uses the same criteria listed above. Providers who regularly work with a given plan know the process better than patients and often get faster results. When choosing a program, ask whether they have previously obtained SCAs with your specific insurer and who manages that process on their end.
Step 6: After UM approves, the SCA team handles the paperwork
At plans like Carelon, after clinical authorization is granted, the request moves to an internal SCA team. That team operates on a 10-business-day processing window. They draft the SCA electronically and send it to the provider for signature. The provider has 10 calendar days to return the signed agreement. If unsigned within 10 days, Carelon loads standard rates as an “Unsecured SCA” and pays at those rates regardless.
For other commercial plans, the rate negotiation may be more flexible. Regional and smaller plans often allow the provider to open at 85 to 90 percent of billed charges and negotiate from there. Carelon, Optum, and Aetna operate on internal fee schedules that are less negotiable: the provider can accept or counter, but the plan may load its standard rate unilaterally.
Step 7: Follow up and track everything
If you have not heard back within 10 business days of the UM approval, call and ask for the status. Document every call with date, representative name or ID, and what was said. Escalation is available at most plans for urgent clinical situations.
Insurer-specific contacts and notes
Carelon Behavioral Health (manages BH benefits for most Anthem, BCBS Anthem-affiliated plans): Provider Services Line: 1-800-397-1630 (Mon–Fri 8am–8pm ET). Members call the number on their ID card. OON policy NM 306.10 is published at carelonbehavioralhealth.com. SCAs are required for commercial plans without OON benefits when network is inadequate. Medicaid and Medicare are reimbursed at allowable rates with no SCA document required. SCA processing is 10 business days after UM approval. Carelon sets fee schedules; providers who refuse are paid at those rates via Unsecured SCA.
Optum Behavioral Health (manages BH benefits for most UnitedHealthcare commercial and Medicare Advantage plans): Provider portal at providerexpress.com. Members call the number on their UHC ID card. OON authorization requests go through ProviderExpress or the member services behavioral health line. Note: UHC/Optum has been reducing OON benefits on some commercial products; verify OON benefit existence before initiating an SCA request.
Aetna Behavioral Health (CVS-owned; manages behavioral health internally for most Aetna plans): Behavioral health provider line: 1-800-872-3862. Members call the member services number on the Aetna ID card. OON and SCA requests require prior authorization; request to speak with behavioral health clinical review. Aetna was fined by state regulators for mental health parity violations in April 2026.
Cigna Behavioral Health: Behavioral health provider line: 1-800-244-6224. Members call the number on the Cigna ID card. Prior authorization is required for all higher levels of care; request OON authorization through behavioral health UM. Fined alongside Aetna and UHC in April 2026 for parity violations.
Blue Cross Blue Shield (non-Anthem plans): Each plan is independent. In Anthem-affiliated BCBS states, Carelon manages behavioral health (see above). Non-Anthem BCBS plans (BCBSMA, Horizon BCBSNJ, BCBSTX, HCSC, etc.) operate independently. BCBSMA has a published Out-of-Network Request Form on provider.bluecrossma.com. For all other non-Anthem BCBS plans: call member services and ask specifically for the behavioral health UM or OON authorization team.
Medicaid managed care plans: No SCA document is typically required at Carelon-managed Medicaid plans; OON authorization is approved clinically and paid at Medicaid allowable rates. Other Medicaid MCOs vary by state. Ask the plan’s behavioral health line specifically about OON authorization for residential or specialty SUD treatment.
Traditional Medicare: SCAs are not available. OON coverage follows standard Medicare rules.
Medicare Advantage: Gap exceptions or network exceptions function similarly to SCAs at some plans but are harder to obtain. Ask the plan’s behavioral health UM line.
What insurers do to resist, and how to respond
They send a provider list. Call every provider, document why each cannot meet your needs, and report back in writing. This defeats the most common counter-move.
They say adequate in-network care exists. If your call log shows otherwise, this is an appealable determination. The MHPAEA argument: a network directory listing providers who are unavailable, full, or clinically inappropriate is not an adequate network under federal parity law. See Insurance Denial and Appeal.
They offer a rate the provider won’t accept. For plans with internal fee schedules (Carelon, Optum), the plan may load the standard rate unilaterally regardless. The provider should weigh accepting versus declining before the Unsecured SCA window closes.
They route you to a case manager. Politely redirect: “I need this routed to Utilization Management for OON authorization, not care coordination. Can you transfer me or flag the record?”
The process stalls. Escalation is available at most plans when there is clinical urgency. Ask UM to flag the case for expedited processing. Document the request.
If the SCA is denied
A denial of OON authorization is appealable as a standard prior authorization denial. Use MHPAEA network adequacy arguments, your documented provider call log, and the letter of medical necessity. External review is available through your state’s insurance department if internal appeal fails. See Insurance Denial and Appeal for the full appeal process.
When the SCA is approved
Get the agreement in writing before treatment begins. Confirm: which services are covered, authorized CPT codes, number of sessions or days, and billing instructions. Keep a copy.
Review your Explanation of Benefits once claims begin processing to verify the terms match what was agreed. Discrepancies are easier to resolve before a large balance accumulates.
If treatment continues beyond the authorized period, request a date extension through the same behavioral health line. At Carelon, extensions are processed clinically and existing SCA rates apply to the extended dates automatically.