Single-Case Agreements

Under certain limited circumstances, members or their providers may apply to obtain behavioral health treatment outside of the Quest network using in-network benefits for a defined period of time. For a list of in-network providers, please visit our online provider search tool or call Quest at 800-364-6352.

If you have an urgent need to seek treatment, please call Quest at 800-364-6352, option 1.

Single-Case Agreement (SCA) Form

Instructions:

All fields must be completed. Incomplete forms may experience a delay in processing. You may be contacted by a representative from Quest regarding answers you provide on the form. Quest may require supporting documentation from treating providers. To avoid a delay in processing, please ensure all contact information is up-to-date. For questions, please call Quest Behavioral Health at 800-364-6352.

Please complete a separate form for each member and/or unique provider. Members 18 or older must consent to file their own requests or designate an Authorized Agent/Provider on their behalf. SCA requests must be received within 30 calendar days of the date of service. Incomplete submissions will delay the review process and may result in the request being denied.

A printable copy of this form is available here or at www.questbh.com/single-case-agreement.

I am a:(Required)

Member

Provider

Member Information

Member Name:(Required)

Member Date of Birth (mm/dd/yyyy):(Required)

Member Street Address:(Required)

Address where the member currently resides.

City:(Required)

State:(Required)

Zip:(Required)

Member Phone Number:(Required)

Member Email:

I ________ give Quest permission to contact me via secured, encrypted email.

do NOT

My preferred method of contact is:(Required)

Phone

Treatment Information

Level of Care being requested:(Required)

Outpatient Therapy

Psychological/Neuropsychological Testing

Intensive Outpatient Program (IOP)

Partial Hospitalization Program (PHP)

Mental Health Inpatient Treatment

Substance Use Detoxification/Rehabilitation (Inpatient)

Mental Health Residential Treatment

Substance Use Residential Treatment

Is the facility licensed for the level of care being requested?

Yes

Provider Information

Practice/Facility Name:(Required)

Practice/Facility Street Address:(Required)

City:(Required)

State:(Required)

Zip:(Required)

Provider Name:(Required)

Provider License Number:(Required)

NPI Number:

Tax ID Number:

Provider/Facility Contact Name for SCA:(Required)

Provider/Facility Contact Email Address:

Provider/Facility Contact Phone Number:(Required)

I ___ give Quest permission to communicate with the SCA Contact via secure, encrypted email.(Required)

do NOT

This field is the same as a signature and gives informed consent for Quest to email information to the email provided below.

My preferred method of contact is:(Required)

Phone

SCA Request Information

Reason for SCA Request (including length of treatment and diagnosis):(Required)

If known, please include procedure codes (CPT) and proposed rates which are applicable to the member's treatment. Not all codes are covered by all Plans and may be subject to additional authorization requirements. All services must be Medically Necessary.

Procedure Code (CPT)

Proposed Rate

Procedure Code (CPT)

Proposed Rate

Procedure Code (CPT)

Proposed Rate

Procedure Code (CPT)

Proposed Rate

If known, please include all procedure codes (Revenue or HCPCS), service description, and proposed rates which are applicable to the member's treatment. Not all codes are covered by all Plans and may be subject to additional authorization requirements. All services must be Medically Necessary.

Procedure Code

Service Description

Proposed Rate

Procedure Code

Service Description

Proposed Rate

Procedure Code

Service Description

Proposed Rate

Procedure Code

Service Description

Proposed Rate

Informed Consent

To evaluate your request for a Single-Case Agreement (SCA), Quest may need to obtain information from your treating provider regarding planning for your care and to determine coverage, including your treatment history. This information is considered your Protected Health Information (PHI). By completing the section below and signing this form, you are allowing your providers to release your Protected Health Information to Quest. We will only contact the provider(s) listed below and only to review information needed to facilitate your SCA request. Quest Behavioral Health values and respects your privacy and will not disclose your information except as specifically outlined below. All PHI is protected as required by federal HIPAA regulations. This consent expires one year from the date of signature below. By my typed signature below, I am authorizing the provider(s) listed to disclose my PHI (or the PHI of minor member for whom I am a legal guardian), to Quest Behavioral Health. I understand that this information will be used to review my request for a Single-Case Agreement. I understand that my provider(s) may not require me to sign this form to continue treatment, but my request for SCA coverage will be denied if I do not sign this form. Purpose of the Disclosure: To allow Quest to receive all PHI needed to make decisions regarding my Single-Case Agreement request. Right to withdraw consent: I understand I may revoke this consent at any time by submitting a written statement to Quest Behavioral Health. I understand that withdrawing my consent does not prevent the release of or apply to information that has already been released as authorized by this consent. Right to obtain a copy of Informed Consent: I understand that I may request a copy of this consent form to be provided at no cost to me. Copies of signed consent(s) may be obtained by contacting Quest at 800-364-6352.

I ______ give my consent for my provider to release my information to Quest.(Required)

do NOT

By typing your name below, you acknowledge that this electronic signature bears the full legal equivalent of a manual signature.

Member/Agent Signature:(Required)

Type full legal name of self or minor dependent for whom you are legal guardian:

Provider Signature:(Required)

CAPTCHA

This field is for validation purposes and should be left unchanged.

The submission of this request does not guarantee approval of a Single-Case Agreement. If approved, members may still be responsible for out-of-pocket costs in excess of in-network cost sharing.