Medicare Advantage single case agreement formSingle Case Agreement (Sca) • January 4th, 2021
Instructions: Providers must first obtain a medical necessity approval for services, prior to requesting a Single Case Agreement (SCA). Please fill out all applicable sections on both pages completely and legibly before faxing or mailing the form to the number or address listed below. Attach any additional documentation necessary for processing the SCA. Information contained in this form is Protected Health Information under HIPAA.
Physical and Behavioral Health Single Case Agreement (SCA) ApplicationSingle Case Agreement (Sca) • August 22nd, 2023
Date of Request: Funding Requested: Medicaid IPRS/State Medicaid Enrolled Provider: Yes No Provider Type Agency ResidentialProvider Solo LIP Group Practice Physical Health Provider Provider Name (as listed in NC Tracks): DBA Name (if applicable): Federal Tax ID: Corporate Address: Agency Mailing Address (if different from corporate address): Agency Billing Address:
Single Case Agreement (SCA) Request FormSingle Case Agreement (Sca) • May 18th, 2022
Medicaid Participant Information Last Name: First Name: Initial: Medicaid ID: DOB: Phone: Primary Insurance Provider: Primary Subscriber ID: Secondary Insurance Provider: Secondary Subscriber ID: Treating Facility/Physician Information Facility Name: NPI: Physician Name: NPI: Coordinating Contact Person: Email: Phone: Fax: Billing Contact Person: Email: Phone: Fax: Referring Physician Information Physician Name: NPI: Contact Person: Email: Phone: Fax: Physician Signature: Date: Requested Service(s) CPT Codes &Modifier, ifapplicable Description Quantity Estimated Admission Date Estimated Discharge Date Required Documentation ☐ Letter of medical necessity from referring provider, indicating why, for example, care at a non-enrolled tertiary care facility is necessary☐ Clinical notes, within the last six (6) months, to support the single case agree
SINGLE CASE AGREEMENT (SCA)Single Case Agreement (Sca) • February 14th, 2017
If there is a member who needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service a Single Case Agreement (SCA) can be requested.
