Navigating Single Case Agreements and Kaiser Out-of-Network Therapy Benefits
Securing a Single Case Agreement (SCA) or out-of-network coverage for therapy through Kaiser Permanente can be complex. This guide outlines steps to improve your chances of success and maximize your mental health benefits.
What Is a Single Case Agreement?
An SCA is a contract between an insurance company and an out-of-network provider to cover a specific client’s care when adequate treatment isn’t available in-network. While SCAs can be a solution, Kaiser is not typically receptive to these agreements.
What Is an Out-of-Network Provider?
An out-of-network provider is a healthcare professional or facility not contracted with your insurance company. While you can still see these providers, coverage typically depends on your plan’s out-of-network benefits, often requiring higher out-of-pocket costs.
Steps to Explore Your Options:
1. Demonstrate Medical Necessity
Diagnosis: A documented diagnosis requiring therapy is very helpful. Having a doctor recommend therapy significantly strengthens your case.
Gaps in Care: Highlight issues such as long wait times or a lack of specialists in Kaiser’s network.
2. Evaluate In-Network Options
Kaiser may recommend seeing therapists within their hospital system.
If you’re referred to in-network providers, you can try finding someone already available-great! Make sure to validate they are still a part of Kaiser. Lists can be inaccurate. Many folks on the lists are unavailability or not in the area of expertise you need. Call a reasonable number (no greater than 10). The associate is unlikely to ask for documentation or proof you can’t get care in their current networks.
If you cannot find someone with the needed specialization, this strengthens your argument for an SCA or out-of-network approval.
3. Propose Your Therapist
Identify an out-of-network provider who meets your treatment needs.
Let Kaiser know they’re qualified and available to provide care.
Be cautious about starting therapy independently, as this may indicate to Kaiser that you’re willing to pay out of pocket, reducing the likelihood of an SCA or out-of-network approval.
Using Kaiser’s Out-of-Network Benefits
If an SCA is not possible, you may still be able to get reimbursed through Kaiser’s out-of-network benefits. Here’s how:
1. Review Your Plan
Check your policy for out-of-network mental health coverage, including deductibles, reimbursement rates, and limits.
2. Contact Member Services
Call the number on your insurance card or use the Kaiser website.
Ask about the reimbursement process for out-of-network therapy.
3. Gather Documentation
Request a superbill from your therapist with:
Name, address, and license details.
Service dates, diagnostic (ICD-10) and procedure (CPT) codes.
Total charges and proof of payment.
4. Submit Your Claim
Complete Kaiser’s claim form for out-of-network services.
Attach the superbill and send it to Kaiser as directed.
5. Follow Up and Appeal if Necessary
Track your claim and address delays or denials promptly.
If denied, review the Explanation of Benefits (EOB) and use Kaiser’s appeals process.
Final Tips
Persistence is key. Highlight gaps in in-network care and clearly demonstrate the necessity of your treatment. With thorough documentation and follow-up, you can improve your chances of receiving coverage.