Single case agreements with the Oregon Health Plan (OHP) can be a confusing and complex process. As a healthcare provider, navigating the OHP requirements can be challenging, especially when you need to provide specialized care to your patients. In this article, we will discuss what single case agreements are, how they work with OHP, and what healthcare providers need to know to successfully navigate this process.

What are Single Case Agreements?

Single case agreements (SCA) are contracts between healthcare providers and insurance companies to provide care for a specific patient or group of patients. These contracts are negotiated on a case-by-case basis to provide specialized care that is not covered under the patient`s insurance plan. SCAs are typically used when a patient requires a treatment that is not included in their standard insurance coverage or when a patient has unique healthcare needs that require specialized care.

How Does SCA Work with OHP?

The OHP is a Medicaid program that provides healthcare coverage to low-income Oregonians. As an insurance provider, OHP sets specific guidelines for services that are covered, and these guidelines are based on medical necessity. However, there are some instances where a patient may need specialized care that is not covered under OHP guidelines. In these cases, healthcare providers can negotiate an SCA with OHP to provide the necessary care for their patient.

What Healthcare Providers Need to Know about SCA with OHP

When negotiating an SCA with OHP, healthcare providers need to keep in mind a few key points:

1. Follow OHP`s Medical Necessity Guidelines: All treatments provided under an SCA must be medically necessary. Healthcare providers need to make sure that the treatment they are providing meets OHP`s medical necessity guidelines.

2. Communication with OHP: Throughout the SCA process, healthcare providers need to communicate with OHP to ensure that all requirements are met and the process runs smoothly.

3. Documentation: Proper documentation of the care provided under an SCA is crucial. Healthcare providers need to make sure that all necessary documentation is complete and accurate to ensure timely and appropriate payment.

4. Timely Filing: Healthcare providers need to ensure that they file all necessary paperwork and claims in a timely manner, as SCA agreements have specific deadlines for filing.

Conclusion

Single case agreements with OHP can benefit both healthcare providers and patients by providing specialized care that may not be covered under traditional insurance plans. However, negotiating an SCA can be complex and require a thorough understanding of OHP`s guidelines and requirements. By following these guidelines and communicating effectively with OHP, healthcare providers can successfully navigate the SCA process and provide the specialized care their patients need.