ModifiedBeacon-Health-OptionsPolicy NM 301.11

SCA (Single Case Agreement) and OON (Out of Network) Reimbursement Policy

Governance of SCA processes and reimbursement for out-of-network behavioral health services delegated to Carelon Behavioral Health, including authorization, rate loading, and exceptions; applies to Carelon entities and members across plan types described in the document.

Policy Summary

PayerBeacon-Health-Options

PolicySCA (Single Case Agreement) and OON (Out of Network) Reimbursement Policy

Policy CodePolicy NM 301.11

Change TypeName updaterate guideline additionsauthorization requirement clarified to 'MAY BE Required' (material changes)

Effective Date

Next Review DateAug 25, 2025

Key ActionSCA Team drafts and transmits SCA electronically with two automated follow-ups and, if unsigned after 10 days, loads OON rates using an Unsecured SCA.

SourceLink

POLICY UPDATE CHANGES

Name of policy updated from Out of Network (OON) Reimbursement Policy and Single Case Agreement (SCA) Process and various scope and definitions added.

New Carelon Behavioral Health rate guidelines in the event that the provider refuses to accept the standard reimbursement were added.

OON Authorization requirement was changed from 'IS required' to 'MAY BE Required' to comply with the No Surprises Act; Member Cost Share added as exception to provider accepting payment as payment in full.

10 business daysstandard SCA team processing timeline

2 automated follow-upsfollow-ups with SCA transmission

100%

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urgent inpatient reimbursement level

60 daysprovider dispute window

90 dayscontinuity of care period

30 daysrefund timeframe (CA)

Coverage and Authorization Criteria

SCA and OON reimbursement criteria

When SCAs are used and how reimbursement is applied across various scenarios.

SCAs are used when Carelon Behavioral Health does not have an established network or cannot meet a member's clinical/services needs with existing contracted providers.

SCA exclusions

SCA(s) are not to be used when there are adequate Carelon Behavioral Health providers for geographic, cultural competency concerns, clinical special needs, including instances when members have out of network benefits.
SCA(s) are not to be used for Medicare or Medicaid members; after clinical authorization these default to applicable Medicare or Medicaid allowables and Carelon Fee Schedules.
SCA(s) are not to be used for Emergency Inpatient Admission; after clinical authorization admissions default to Carelon Fee Schedules consistent with plan benefit design and member in-network cost share applies.
SCA(s) are not to be used for Claims Exceptions, when Carelon is the secondary payer, for COS/COC scenarios where other rules apply, or when an in-network provider requests short-term coverage; these are handled without an SCA and redirected as appropriate.

Reimbursement allowances

Urgent services without an OON benefit: Carelon allows reimbursement for urgent services provided by OON professionals and facilities unless state/federal regulations or client contracts indicate otherwise.
Non-urgent services without an OON benefit: Carelon allows reimbursement for non-urgent professional/outpatient services and inpatient facility services (upon stabilization) when there is no access/availability of in-network providers, for plan-directed care, or for continuity of care, with prior clinical approval for plans without OON benefits.
Services with an OON benefit: Carelon allows reimbursement according to the plan's benefit package/Evidence of Coverage for OON behavioral health services without prior approval for plan designs that include an OON benefit.

Emergency care reimbursement

Outpatient emergency ER services are reimbursed for covered services following the Claims Emergency Service Policy; OON authorization and an SCA are not required.
Inpatient emergency admissions are reimbursed at 100% of Carelon Fee Schedules consistent with plan benefit design without a signed SCA; Out-of-Network Authorization may be required and member in-network cost share applies.

Exclusion screening is required for OON providers; failure to provide information necessary for exclusion screening may result in denial of OON authorization and claims.

OON Authorization Clinical Criteria

Clinical Care Manager evaluates OON authorization requests against the following criteria (at least one required):

ANY of the following

No network resources (facilities, practitioners, or EAP affiliates) for required covered services within access standards of the member's residence.
Network facilities are at capacity and network practitioners/EAP affiliates cannot accept new patients/clients.
Clinical or service needs (such as specialty, language, cultural sensitivity, gender) cannot be met by available network resources.
Member preferences that are relevant to treatment outcome cannot be met by available network resources.
Authorization supports necessary continuity of care for a member with a history of treatment with an out-of-network provider per contractual obligations (see continuity rules); if member is new to the plan, SCA not required and standard continuity process applies.

Non-authorizing scenarios

Scenarios not sufficient alone to authorize OON services:

ANY of the following

A member historically paying out-of-pocket to see an OON provider does not, by itself, constitute a valid reason to authorize OON services.
A provider who was part of an in-network group leaving that group and becoming OON (the member's historical relationship) does not, by itself, constitute a valid reason to authorize OON services.

When there are adequate network providers to meet the member's needs and no compelling reasons for OON authorization, Carelon staff will inform parties of the decision not to proceed; denial and appeal rights apply per contract.

State-specific coverage rules

Coverage stance and billing rules as specified by state addenda:

Out-of-State Medicaid: When a Medicaid member is treated in a non‑home state, the provider must accept the member's home state Medicaid fee schedule or reimbursement methodology; billing the member for the difference between the Medicaid‑allowed amount and provider charges is prohibited (42 CFR 447.15).

Out-of-State Medicaid: Services not covered by Medicaid are not covered; a Medicaid member may only be billed for a non-covered service if prior written approval was obtained.

California: The plan shall arrange for non‑network medically necessary services if unavailable in‑network; a member's cost for medically necessary non‑network referrals shall not exceed applicable in‑network copayments, coinsurance, and deductibles. OON providers must refund overpayments to the member within 30 calendar days and pay 15% annual interest on late refunds.

Washington: For court‑ordered involuntary MH/SUD treatment and certain authorized stays for uninsured/underinsured individuals, Carelon will not require an SCA to reimburse eligible out‑of‑network hospitals and E&T centers according to the IPPS rate or WA Carelon Behavioral Health Fee schedule; similar reimbursement without SCA applies for other authorized voluntary MH/SUD stays for uninsured individuals.

Rate Loading, Codes, and Timelines

Rate loading for authorized service codesmixedCovered

Service Codes

Rates loaded for the Service Codes and Dates of Service authorized by Clinical

Rate loading and sourcemixed

Rates are loaded for service codes and dates of service authorized by clinical team; reimbursement levels set by line of business or Medicaid/Medicare fee schedules

Reimbursement basis for WA authorized staysmixed

IPPS	Inpatient Prospective Payment System rate as posted by WA HCA for OON hospitals
WA Carelon Behavioral Health Fee schedule	WA Carelon Behavioral Health Fee schedule for eligible OON freestanding Evaluation & Treatment Centers and other voluntary authorized stays

SCA signature response window (inv-08)

SCA signature response windowSCA Team sends SCA electronically with two automated follow-ups; provider must return signed SCA within a 10-day calendar period

If unsigned within windowIf signed SCA not received within 10-day calendar period, SCA Team will load OON rates with an Unsecured SCA

Standard SCA Team timelineStandard SCA Team processing timeline is 10 business days (unless escalated)

Provider dispute window (inv-09)

Provider dispute/reconsideration windowProvider must submit disputes or requests for reconsideration in writing within 60 calendar days from the date of the claim remittance statement

Provider Intake, Authorization, and Processing Workflow

Prior Authorization

OON authorization intake and pend

The provider or member may request authorization for an out-of-network (OON) service by calling the phone number on the member's ID card or the number listed in the member's benefits. CCM receives the OON request, confirms the member is actively enrolled, verifies that there is no available in-network provider for the medically necessary service, and documents the request in the intake system.

Provider or member calls phone number on member ID or benefits to request OON authorization.
CCM confirms member enrollment and medical necessity for the requested OON service.
CCM documents the OON request in the intake/authorization system.

Prior Authorization

CCM and Authorization Workflow

The Clinical Care Manager (CCM) / Network Support Team will attempt to redirect the member to an available in-network provider when a compatible option exists. The CCM verifies OON provider eligibility, confirms the provider is not excluded from state or federal programs, and documents any in-network provider unavailability. If member care cannot be redirected, the CCM proceeds with the OON authorization workflow and places the authorization on hold per line of business rules.

Key Definitions and Regulatory References

Single Case Agreement (SCA) — definition (inv-16)

DefinitionA Single Case Agreement (SCA) is an agreement between Carelon Behavioral Health and an out-of-network provider to provide covered service(s) to a specific member(s)

Purpose in processSCA is drafted by the SCA Team using a standardized template and sent to the provider for signature to establish authorized rates and dates of service

Unsecured SCAIf provider is unresponsive or declines maximum allowed rate, an Unsecured SCA may be loaded to apply OON rates

Out of Network (OON) Provider — definition (inv-17)

DefinitionAn Out-of-Network (OON) Provider is a provider that has not contracted with the health plan/Carelon Behavioral Health for the covered services

Implication for reimbursement

Policy Summary

PayerBeacon-Health-Options

PolicySCA (Single Case Agreement) and OON (Out of Network) Reimbursement Policy

Policy CodePolicy NM 301.11

Change TypeName updaterate guideline additionsauthorization requirement clarified to 'MAY BE Required' (material changes)

Effective Date

Next Review DateAug 25, 2025

Key ActionSCA Team drafts and transmits SCA electronically with two automated follow-ups and, if unsigned after 10 days, loads OON rates using an Unsecured SCA.

SourceLink

On This Page

Transportation or available support systems enable the member to only access an out-of-network resource.

Available network resources indicate they cannot meet the member's service needs.

A network facility is not contracted for a specific required modality.

Emergency treatment or admission requires an out-of-network provider.

The facility or practitioner terminated network status during the member's course of treatment and continuation is requested; continuity may apply through active treatment or up to 90 calendar days, whichever is shorter.

New client transition as part of an implementation plan or new members joining with prior history with the provider may result in out-of-network authorization per contract/transition benefits.

Member is a full-time student outside the geographic area of the network when allowed by the benefit plan.

Confidentiality issues exist (e.g., member is a provider or employee of Carelon or a managed plan) requiring out-of-network treatment.

An administrative decision by the client or Carelon Behavioral Health has been made to approve an out-of-network provider.

Submission addressDisputes or requests for reconsideration should be submitted to the address listed on the top of the remittance statement

Applicable to claim payment decisionsRight to dispute applies when OON Provider disagrees with a claim's payment decision

Refund timeframe (inv-10)

Refund timeframe to member (CA)OON provider shall refund any overpayment to the member within 30 calendar days after receiving payment from the member

Interest on late refundsIf refund not made within 30 calendar days, interest accrues at 15% per annum starting when payment was received

Automatic inclusion of interestOON provider shall automatically include all accrued interest in the refund without requiring member request

CCM attempts redirection to an in-network provider when appropriate.
CCM verifies OON provider eligibility and exclusion status against state and federal program lists.
If redirection isn't possible, CCM proceeds with OON authorization and pends the auth according to plan (FlexCare or Connect).
FlexCare: authorization is pended in FlexCare until SCA process is complete.
Connect: authorization is pended in ServiceConnect with a hold code to prevent claims payment until SCA is complete.
Provider may request a date extension; if clinically approved, CCM updates the existing authorization with new dates and applies existing reimbursement rates.

Note

SCA Team Actions and Timelines

The SCA Team validates the inquiry information, drafts the Single Case Agreement (SCA) using the standardized Contraxx template, and executes a defined outreach cadence. The standard SCA Team timeline is 10 business days for processing inquiries received in order, unless escalated.

SCA Team confirms required information is present; incomplete inquiries are returned to the CCM for clarification.
SCA Team drafts the SCA in Contraxx using the standardized approved template and sends it electronically to the provider with two automated follow-ups within a 10-calendar-day period.
If a countersigned SCA is received within 10 calendar days, the SCA Team loads rates into the appropriate system (ServiceConnect Review Tab for Connect plans; Provider Configurations/NetworkConnect for FlexCare plans) for the authorized service codes and dates of service.
If the provider is unresponsive or declines the maximum allowed OON rate after required outreaches, the SCA Team will load OON rates using an Unsecured SCA.
SCA Team uploads the countersigned SCA to ServiceConnect, returns the inquiry to the CCM requestor, and closes the SCA event after provider configuration processing is complete.

Billing Rule

Post-authorization Processing

After the SCA is finalized (or an Unsecured SCA is loaded), the CCM updates the authorization, completes required outreach, and closes the ServiceConnect inquiry. Claims are processed to pay according to the authorization and the loaded SCA terms.

CCM updates the member authorization (un-pends, removes hold code, or otherwise updates the auth) after receiving SCA confirmation.
CCM completes any necessary provider or member outreach and closes the inquiry within 7 business days in ServiceConnect.
Claims Team processes received claims according to the rates and authorization on file; providers receive Remittance Advice.
Claims processors review and work the queue daily to (re)process claims impacted by the SCA.

Note

SCA requirements and WA HCA exceptions

Washington State HCA-authorized involuntary treatment stays have specific exceptions: an SCA is not required to reimburse authorized eligible providers for certain court-ordered or authorized stays, and reimbursement will follow the applicable WA HCA or Carelon fee schedules/rates regardless of in-network status.

For OON hospitals (WA-certified Community or Psychiatric Hospitals for E&T services), no SCA is required; reimbursement follows the IPPS rates posted by WA HCA.
For OON freestanding Evaluation & Treatment Centers licensed/certified for E&T services, no SCA is required; reimbursement follows the WA Carelon Behavioral Health fee schedule.
For other voluntary MH or SUD treatment authorized stays for uninsured individuals at OON facilities, no SCA is required; reimbursement follows the WA Carelon Behavioral Health fee schedule.

OON providers may be reimbursed per policy criteria; eligibility may be subject to exclusion screening and enrollment status

Behavioral OON AuthorizationRefers to when a member needs prior approval from the health plan/Carelon Behavioral Health to receive behavioral health services from an OON provider

Regulatory references (inv-18)

Federal regulations cited42 CFR 422.105 and 42 CFR 422.111 referenced for Medicare Advantage plan provisions

Deficit Reduction Act (DRA) 2005DRA §6085 is cited regarding Medicaid emergency service payment and acceptance as payment in full

EMTALAEmergency Medical Treatment & Labor Act (EMTALA), Section 1867 of the Social Security Act, is cited regarding emergency screening, stabilization, and transfer obligations

Single Case Agreement (SCA) — alternate reference (inv-19)

Alternate reference/titleSingle Case Agreement (SCA) — see definitions and SCA Team process references for scope and usage

Policy locationsSCA definition appears in Acronyms and Definitions and SCA Team process described in SCA Team section

Use casesSCAs are used when Carelon lacks network capacity or cannot meet member's clinical/service needs

Member Cost Share — definition (inv-20)

DefinitionMember Cost Share = member deductible, copayment, or coinsurance applicable per plan

Payment acceptanceProvider shall accept standard OON reimbursement as payment in full for services rendered except for Member Cost Share

Exception handlingIf provider refuses standard reimbursement, allowed rate will be loaded per plan benefit design; Member Cost Share remains applicable

Out of State Medicaid Reimbursement — policy (inv-21)

Home-state Medicaid ratesWhen a Medicaid member is treated out-of-state, the provider must accept the member's home state Medicaid fee schedule or reimbursement methodology

Prohibition on balance billingBilling a Medicaid member for the difference between the Medicaid-allowed amount and provider charges is prohibited by 42 CFR 447.15

Non-covered servicesServices not covered by Medicaid will not be covered; providers may bill member for non-covered services only with prior written approval

In‑network cost‑sharing amount (California) — handling (inv-22)

California in-network cost-sharingIf a member receives covered services from a contracted facility that result in OON provider services, the member shall pay no more than the in-network cost-sharing amount

Provider billing and noticeOON provider shall not bill or collect more than the in-network cost-sharing amount and Carelon shall inform the member and OON provider of the amount at time of payment

Refund and interest obligationsIf OON provider received more than the in-network cost-sharing amount, the provider must refund the overpayment within 30 calendar days and pay 15% per annum interest if late