Emblem Health Single Case Agreement: A Comprehensive Guide
If you are an Emblem Health plan holder, you may have come across the term single case agreement. A Single Case Agreement (SCA) is an agreement between an insurance company and a healthcare provider that allows a patient to receive care from an out-of-network provider. In this article, we will dive into the details of emblem health single case agreement, so you can better understand how it works.
What is an Emblem Health Single Case Agreement?
An Emblem Health Single Case Agreement (SCA) is a specific type of out-of-network agreement that Emblem Health offers to its members. SCAs are designed for patients who need to see a healthcare provider outside of their network because they require specialized care that is not available within the network.
For example, if you have a rare medical condition that requires treatment from a specialist who is not in Emblem Health`s network, you may be eligible for an SCA. In this scenario, Emblem Health will pay the out-of-network provider at the in-network rate, meaning the patient is only responsible for their copay, coinsurance, and deductible.
When is an Emblem Health Single Case Agreement needed?
An SCA is needed when a patient requires treatment from a healthcare provider who is not in-network with Emblem Health. This typically happens when a patient requires specialized care that is not available within Emblem Health`s network. An SCA may also be necessary if there is a lack of providers within the network, or if the patient is in an emergency situation.
How can I get an Emblem Health Single Case Agreement?
To obtain an SCA, you must first get a referral from an in-network provider that confirms the need for treatment from an out-of-network provider. Once the referral is approved, Emblem Health will work with the out-of-network provider to negotiate the terms of the agreement. The healthcare provider must agree to the terms of the agreement before any treatment is provided.
It is important to note that not all out-of-network providers will be willing to enter into an SCA. Some may require full payment upfront, which means the patient is responsible for filing a claim to receive reimbursement from Emblem Health.
What are the benefits of an Emblem Health Single Case Agreement?
The primary benefit of an SCA is access to specialized care that is not available within Emblem Health`s network. Another benefit is that the patient will only be responsible for their copay, coinsurance, and deductible, rather than the full cost of treatment.
It is important to note that SCAs are not automatic, and each case is evaluated individually. Emblem Health will only approve an SCA if they determine that it is in the patient`s best interest and necessary for their medical treatment.
Conclusion
An Emblem Health Single Case Agreement is a valuable tool for patients who require specialized care that is not available within the health plan`s network. It is important to work with an in-network provider to obtain a referral and to ensure that the out-of-network provider agrees to the terms of the agreement. While not all out-of-network providers are willing to enter into an SCA, for those that do, it can provide access to necessary medical treatment at a reduced cost.
