Single Case Agreement Template Form – Fill Out and Use This PDF

SUBMIT TO:

Cenpatico Single Case Agreements

FAX 866.374.1576

SINGLE CASE AGREEMENTS FOR BEHAVIORAL HEALTH SERVICES

What is a Single Case Agreement?

On occasion, Cenpatico grants exceptions, called Single Case Agreements, that allow individuals whose beneit plans do not include out-of-network beneits to see a non-contracted professional utilizing their in-network beneit.

What conditions must exist for a Single Case Agreement to be made?

•An area is geographically remote for any in-network Cenpatico provider.

•A clinical specialty is not available within Cenpatico’s network.

•Continuity of Care: If there is evidence that the individual might be a danger to him/herself or others if required to transition to an in-network professional.

What must a non-contracted professional do to obtain a Single Case Agreement?

•Review all of the information on this sheet.

•Complete this form and fax to Cenpatico Single Case Agreements at 866.374.1576. You can download a copy of this form at cenpatico.com.

Single Case Agreements are authorized on a case-by-case basis.

If a Single Case Agreement is authorized, what are the terms and conditions of working with Cenpatico?

Non-contracted professionals must agree to the following:

•Arrangement is for a Single Case Agreement for only the individual for whom it was authorized and for only those services authorized, and there are no in-network providers whose qualiications or specialties match those required to adequately treat the individual.

•To accept agreed upon rate & copayments, coinsurance and deductibles as payment in full.

•The enrollee cannot be billed for services that Cenpatico declines to authorize unless the individual has agreed to pay for any such services in advance and in writing.

MEMBER INFORMATION

NAME

DATE OF BIRTH			MEMBER ID #
IS THIS A MEDICARE MEMBER		YES	NO
	PROVIDER INFORMATION
	PROVIDER NAME		LICENSURE (MD, PhD, LCSW or LPC, etc.)
	DATE OF BIRTH		SOCIAL SECURITY NUMBER
	GROUP NAME (IF APPLICABLE)
	TAX ID		RENDERING PROVIDER NPI
	MEDICAID NUMBER		PHONE NUMBER
	MEDICARE NUMBER (IF APPLICABLE)		FAX NUMBER
	POINT OF CONTACT NAME		EMAIL ADDRESS
	MAILING ADDRESS		CITY, STATE ZIP CODE
	DATES OF SERVICE
	PROCEDURE CODE(S) REQUESTED		DIAGNOSIS CODE

Please note that in order for your request to be processed, ALL OF THE ABOVE FIELDS MUST BE COMPLETED. In addition to this form, please submit your W9, Proof of Insurance, and a copy of your license.

WHEN COMPLETE, FAX TO: Cenpatico Single Case Agreements 866.374.1576