In-network, out-of-network, and single-case agreements: what "we work with your insurance" means.

Authored by the MLJ Clinical Team. Reviewed under board-certified psychiatric oversight. Last updated September 2026.

• "We work with" a plan can mean one of three things: a network contract, use of your out-of-network benefits, or a single-case agreement negotiated for you alone.
• Network status determines which deductible applies, whether the program can bill you for the difference, and how much the plan pays; it is verified before admission, never assumed.
• A single-case agreement is a one-patient contract that can bring in-network cost-sharing to a program that is otherwise out of network, usually when the plan cannot offer an equivalent option nearby.
• Prior authorization opens the door; concurrent review keeps it open, on a cadence that runs from every day or two in detox to every couple of weeks in IOP.
• A denial is a decision, not a verdict: internal appeals, peer-to-peer review, and California's Independent Medical Review process exist for exactly this situation.

• The three things "we work with" can mean
• The five plans, one at a time
• What a single-case agreement is and when it happens
• Deductibles, allowed amounts, and balance billing
• Prior authorization: what the reviewer is asking
• Reauthorization cadence by level of care
• When a plan says no

The three things "we work with" can mean.

When a treatment program lists insurers on its website, it is describing relationships, and relationships come in three grades. The first is a network contract: the program has signed an agreement with the insurer that fixes the rate for each level of care, requires the program to accept that rate as payment in full, and places the program in the plan's directory. If you have an HMO or an EPO, this is usually the only grade that produces coverage at all.

The second is out-of-network benefits. Most PPO plans pay something toward care from providers they have no contract with, at a lower percentage and against a separate, higher deductible. The program bills the plan, the plan pays its share of what it considers a reasonable charge, and the program may bill you for what remains. Whether that residual is small or enormous depends on the gap between the program's charge and the plan's "allowed amount," which is why the number matters more than the label.

The third is a single-case agreement, a contract negotiated for one patient, one episode of care. It exists because plans have an obligation to provide access to covered services, and when the network cannot supply what a member clinically needs, the plan can agree to pay an out-of-network program at a negotiated rate, often with in-network cost-sharing applied. Every one of the five plans below can, in principle, be reached through any of these three grades. Which one applies to you is the first thing our admissions team establishes when you submit your insurance for verification, and we will tell you which lane you are in before you decide anything.

The five plans, one at a time.

Insurers are not monoliths. Each of the five carriers we work with sells dozens of products, and a Cigna PPO bought through an employer behaves differently from a Cigna plan bought on the exchange. What follows is how each carrier tends to organize behavioral-health coverage, so you know who you are dealing with. It is not a promise about your specific plan, which only verification can supply.

Aetna administers behavioral-health benefits through its own behavioral-health unit, and its employer PPO plans commonly carry out-of-network benefits for residential care. Anthem, which operates Blue Cross in California, sells both PPO and HMO products; the PPO products generally include out-of-network coverage, while HMO members usually need a referral pathway or an agreement to receive care outside the network. Cigna routes behavioral-health authorization through Evernorth, its health-services arm, so the reviewer our clinicians speak with is often not the same organization that appears on your card. UnitedHealthcare does the same through Optum, and Optum's reviewers are among the most exacting in the industry about ASAM-based documentation.

Kaiser Permanente Southern California is different in kind. Kaiser is an integrated system that delivers most care inside its own facilities, and coverage for outside residential treatment typically flows through a referral or authorization from Kaiser itself rather than through a conventional out-of-network benefit. Kaiser members can and do receive care at outside programs, but the path runs through Kaiser's own addiction-medicine department, and the timeline is set by their process. If you are a Kaiser member, our admissions team will explain how that works for your plan and what you can do to move it along. For any of the five, if you are covered through an entertainment-industry health plan or a union trust, ask admissions to verify; those plans are administered in their own ways and we do not assume anything about them.

What a single-case agreement is, and when it happens.

A single-case agreement, sometimes called a network exception or an ad hoc contract, is a written agreement between a plan and an out-of-network provider covering one member's care for a defined period. The plan agrees to a rate; the provider agrees to accept it and not bill the member beyond the in-network cost-sharing the agreement specifies. From your side, the effect is that a program outside your network is treated, for this episode, as if it were inside it.

Plans do not grant these casually. The argument that works is clinical and geographic: the member needs a level or type of care the network cannot supply within a reasonable distance or time frame. A person who needs medically supervised detox for benzodiazepines and alcohol together, with psychiatric oversight for a co-occurring condition, in a small setting because of a documented reason group-heavy programs have failed, is a stronger candidate than a person who simply prefers a nicer house. Continuity is another recognized argument: if you have completed residential with us and need to step down to PHP, a plan may agree that changing clinical teams mid-course is a worse outcome than paying us for the next phase. Timelines vary; an agreement can be reached in a day when the plan is motivated and take a week when it is not. Our team has negotiated many, and we will tell you honestly whether yours is a strong case before you wait on it.

Deductibles, allowed amounts, and balance billing.

Most PPO plans carry two deductibles, an in-network one and a larger out-of-network one, and the two are usually tracked separately. Money you have already spent on in-network care this year may not count toward the out-of-network deductible at all. The same is true of the out-of-pocket maximum; plans often set a higher out-of-network ceiling, and some do not cap out-of-network spending at all. This is the arithmetic behind the advice to know your lane before you compare programs: the same daily rate produces a different bill in each.

Out of network, the plan also decides what it considers a reasonable charge, called the allowed amount, and pays its coinsurance percentage of that figure rather than of what the program billed. If the program charges more than the allowed amount, the difference is called the balance, and an out-of-network program is legally permitted to bill you for it in most non-emergency situations. Under a network contract or a single-case agreement, balance billing is prohibited. Our policy is simple: before admission, you receive a written estimate that shows your deductible status, your expected coinsurance, and whether any balance could be billed to you. If we cannot give you that, we have not finished verifying, and we will say so. Our page on what happens after verification describes that estimate in detail.

Prior authorization: what the reviewer is asking.

For detox and residential care, nearly every plan requires authorization before the first covered day. A clinician on our team calls a care manager on the plan's side and walks through your situation using a shared framework, most often the ASAM criteria: withdrawal risk, medical conditions, psychiatric conditions, readiness, relapse potential, and living environment. The reviewer is trying to answer one question: does this person meet criteria for this level of care, or could a lower level do the job safely? A history of failed outpatient attempts, a withdrawal syndrome that could turn dangerous, a co-occurring diagnosis that needs daily psychiatric contact, and a home environment where use is easy all point toward residential. We document what is true; we do not exaggerate, because reviewers remember programs that do.

Authorization typically arrives the same day for a clean case and within a few business days for a complicated one. It comes with a number and a span of approved days. For outpatient levels the process is lighter; many plans require notification rather than authorization for IOP, though that is changing. Under federal parity rules, described on our paying for treatment hub, plans cannot apply authorization requirements to substance-use care that are more stringent than the ones they apply to comparable medical care. That does not stop them from asking questions; it does give us a standard to hold them to.

Reauthorization cadence by level of care.

The authorization you receive at admission is never for the whole stay. It covers a block of days, and before the block ends our clinical team submits an update and the plan decides whether to approve the next one. This is concurrent review, and its rhythm differs by level of care because the plan's risk differs. In detox, where the daily cost is highest and the medical picture changes quickly, reviews are frequent. In IOP, where you are living at home and the cost per week is modest, they are sparse.

Two consequences follow. First, you will occasionally hear that "insurance approved through Thursday." That is not a discharge date; it is the end of the current block, and the next review is already scheduled. Second, the documentation that satisfies a reviewer is the same documentation that good treatment produces anyway: what changed this week, what has not, and what the plan is for the week ahead. A small program with a true one-to-one ratio has an advantage here, because the clinician writing the update knows you well enough to write something true.

When a plan says no.

Denials come in two shapes: a refusal to authorize a level of care at admission, and a refusal to extend an authorization mid-stay. Both trigger the same sequence. First, a peer-to-peer review, in which our psychiatrist or physician speaks directly with the plan's medical director; a large share of denials reverse at this step because the initial reviewer lacked information. Second, a formal internal appeal, which for urgent situations the plan must decide quickly under federal rules. Third, external review. In California, members of plans regulated by the Department of Managed Health Care can request an Independent Medical Review, in which physicians outside the plan decide whether the denied care was medically necessary; the plan is bound by the result.

While an appeal runs, treatment does not stop. We tell you what the plan said and what it will cost to continue while we contest it, and you decide with full information. Some families choose to pay privately for a bridge of days; some step down to a covered level of care with the same team, which is one of the quiet advantages of a single continuum. Either way, you learn about a denial from a person who explains it, not from an envelope. Our private pay page describes what it looks like to opt out of this process entirely, and why some clients with excellent coverage do.

• Paying for treatment — the hub: what drives cost and how a claim moves.
• After you submit insurance verification — what admissions calls back with and when.
• Private pay — stepping outside utilization review altogether.
• The ASAM criteria explained — the framework every reviewer uses.
• Medically supervised detox — the level of care where authorization matters most.
• Does insurance cover addiction treatment? — common denials and how they are resolved.