Protected: Insurance for Teen Mental Health Treatment: What is a Single Case Agreement?

Single Case Agreements

A Single Case Agreement (SCA) allows an out-of-network provider to be considered in-network for a single case involving one patient/client. With an SCA in place, a family is only responsible for copays and in-network deductibles. In many cases, this makes teen mental health/addiction treatment more affordable. It allows teens to receive treatment at a treatment center that’s not in-network with their family insurance provider.

When do insurance companies grant Single Case Agreements?

Single Case Agreements are often granted when the individual is in need of specific treatment and no treatment center in-network on the insurance panel offers the specialized treatment. They may also be granted if an in-network treatment center is too far away or full. If a Single Case Agreement is granted, Evolve will work with the insurance company on the terms of the agreement.

What you need to do to get a Single Case Agreement:

1. Research treatment centers in your area. Look on your insurance company website for treatment centers in your area.
2. Call each one and document the services they do/do not offer. Document who you spoke with and why it’s not the best place for your child.
3. Call your insurance company and make the request for a Single Case Agreement. Be sure to have your documentation available so they know you’ve done your due diligence. Explain why none of the in-network treatment centers are right for your teen’s specific needs.

Remember, ultimately, a Single Case Agreement is a contract between the primary member of the insurance (usually the parent) and the insurance company. Therefore, the treatment center needs you to partner with them to start the process. That means parents  – you – need to do some of the leg work by advocating for your child and communicating regularly with the insurance company. In our experience, receiving a SCA is more likely when both the treatment center and the parents work together to advocate for the teen.

What should you say to your insurance company to initiate a Single Case Agreement for Evolve?

When you call your insurance company, use the following script to help initiate the process of getting a Single Case Agreement for Evolve:

• “I’m calling to request a Single Case Agreement to have my teen attend an out-of-network provider who specializes in an evidence-based treatment for…” Let them know if your child requires primary mental health or dual diagnosis treatment. Also, let them know if they need a specific type of treatment modality such as Dialectical Behavior Therapy (DBT).
• “I’ve been unable to find an in-network provider who can offer my child the treatment that my child needs and my plan does not have out-of-network benefits and/or I can’t afford an out-of-network provider without a Single Case Agreement.”
• “I’ve called and received a list of the providers that are in-network, and also looked on your website and have called all of the providers on the list, and they don’t offer what my child needs.”
• “How can I start this process? I’ve identified Evolve as the treatment center best suited for my teen.”

How do you justify your child’s need for treatment at Evolve?

When you talk to your insurance provider on the phone, tell them the following:

1. My child’s need for treatment at Evolve is justified by suicidal thoughts and/or hospitalizations and a history of self-harm. Their therapist recommends DBT. Their therapist indicates my teen requires 24/7 supervision.
2. Evolve offers three individual therapy sessions, two family sessions, and a psychiatrist session each week.
3. Treatment is delivered through a team of highly qualified, licensed individuals.
4. Evolve offers DBT skills coaching for the client in order to help them utilize their skills once they discharge from the teen treatment center. Skills coaching is evidence-based and successfully reduces the symptoms of mental health disorders such as depression and anxiety.

What will Evolve’s role be in requesting the Single Case Agreement?

Once we understand your insurance company is willing to consider a Single Case Agreement, we’ll start the process.

For residential treatment, the process goes like this:

1. If we’re considering a residential level of care for your teen, we will first schedule a Pre-Admission Phone Assessment with you/the parent.
2. We’ll ask you to provide us with any documentation supporting your teen’s need for residential treatment (i.e. records from a hospital, therapist, or psychiatrist. Or we’ll ask for documentation from a lower level of care.)
3. Once we complete the pre-admission process, we bring in our Utilization Review Team to request authorization.
4. Once everything is complete on our end and your teen is cleared for admission to Evolve, we’ll call your insurance company to ask for a Single Case Agreement.
5. We’ll ask the insurance company to approve the SCA. We typically give them an admission date and location.
6. At times, they give us an answer right away. Sometimes, though, we wait for a call back. At all times, we keep you informed and even ask for your help in contacting them if there’s a problem.
7. Once we get the go-ahead for a SCA, we’ll work with you on a supportive admission.

A Step-Down Single Case Agreement

Let’s say you have a SCA already in place for your teen’s residential treatment. Once your teen discharges from the residential treatment center and needs to step down to a partial hospitalization (PHP) or intensive outpatient (IOP) level of care, what should you do?

If you had an SCA for residential treatment, you’ll need a new one when your child steps down to the next level of care (PHP or IOP).

There are also times when Evolve may not need an SCA for residential treatment but will need one for stepping down to an out-of-network IOP or PHP. Our Aftercare and Discharge Planner will alert you to this need and will likely have you, the parent, tour the facility, speak with our staff, and advise you to speak with the other programs to see if they have space and are appropriate.

If these other IOP or PHP programs do not meet your teen’s needs, you report back to us so we can call in a step-down SCA while discussing discharge with the care manager.

If we work together, we can better ensure that we do not have to open a new case with your insurance company, which makes it easier to secure an SCA for the next level of care. Again, your teen cannot begin PHP or IOP until your insurance provider approves the new SCA. That’s why it’s important for you to encourage your insurance company to put a step-down SCA in place.

SCAs for PHP and IOP

If your teen requires a partial hospitalization (PHP) or intensive outpatient program (IOP):

1. We’ll schedule a time for you and your teen to visit one of our IOP/PHP locations for a tour and assessment. Once that’s complete, we start the process of calling your insurance provider to request an SCA. At this point, you should’ve already contacted your insurance company to lay the groundwork for an SCA.
2. We’ll ask you to provide us with any documentation supporting the PHP or IOP level of care. For instance, if your teen is coming from a hospital, we’ll need hospitalization records. If they’re stepping down from another treatment center, we’ll need those records.

Your teen cannot start PHP or IOP treatment until the SCA is approved, even in those cases where you may have out-of-network benefits but cannot afford them.

The Key Elements: Document and Communicate

The most important thing about this process is the correct combination of documentation and communication. We will collaborate with you to make sure we document the treatment process accurately. We will communicate with you and your insurance provider in a timely and efficient manner. We’re one hundred percent committed to providing your teen with the best treatment available. We’ll work with you and your insurance provider to ensure your teen receives the treatment they need.