When your provider doesn't take insurance.

What “out of network” and “private pay” mean.

An out-of-network provider does not have a contract with your health plan. Private pay means you pay the provider directly. A therapist may offer only private-pay appointments, even when you have insurance.

For a California mental-health or substance-use denial, these terms help explain the dispute. They do not, by themselves, decide whether your plan must pay. Check your benefits, the denial reason, and whether an appropriate in-network provider can actually see you.

A single case agreement, in three sentences.

A single case agreement (SCA) is an agreement between a health plan and an out-of-network provider to cover specified care for one member. You can ask the plan to consider one when you cannot get appropriate care in its network or need to preserve an established course of treatment. The plan and provider must agree on the terms, so asking does not guarantee approval or payment.

When a plan may have to arrange care.

If no appropriate in-network provider is actually available within the timely-access standards that apply to your plan, you can ask the plan to arrange care outside its network at in-network cost sharing. A name in a directory is not the same as an available appointment. The plan may arrange another appropriate provider; this does not guarantee your preferred provider or an SCA.

Health & Safety Code § 1367.03: Read the plain-English guide to timely access and network adequacy(Opening soon).

Continuity of care may also matter if your provider leaves the network or a qualifying plan change interrupts ongoing treatment. It can allow care with an established provider for a limited period when the conditions are met. Ask your plan and provider whether your situation qualifies.

Health & Safety Code § 1373.96: Read the plain-English guide to continuity of care(Opening soon).

These California protections depend on your plan. Self-funded employer plans follow a different federal route.(Opening soon)

Make the request one step at a time.

1. Document the search. Keep the provider names, dates you called, whether they accept your plan and new patients, the earliest appointments offered, and any reason the care would not meet your needs. Ask your clinician to explain relevant treatment needs.
2. Ask in writing. Ask the plan to locate an actually available provider or consider out-of-network care at in-network cost sharing, including an SCA. Request a written answer and confirm authorization, your share of the cost, and the provider's agreement before relying on coverage.
3. Escalate to a grievance. If the plan denies the request or does not resolve the access problem, use its grievance process. Attach the search record and written responses, and check the instructions and deadlines on your notice.
4. Check the next review route. A medical-necessity denial may qualify for Independent Medical Review (IMR). An access or network problem may instead need a regulator complaint. Confirm your regulator and the available route; if care is urgent, ask the plan or regulator about urgent help now.

What Parity can draft for this.

For supported California plans, Parity's out-of-network denial ground describes the request this way:

Your insurer denied coverage because the provider is out-of-network. Your grievance will describe the in-network options you actually checked and ask the plan to arrange appropriate care at in-network cost sharing, including consideration of a single case agreement with the out-of-network provider.

You review the draft, check the facts and current filing instructions, and decide whether to send it. Parity does not contact your plan or negotiate an agreement for you.

Read the single case agreement and out-of-network playbook →(Opening soon)

Ketamine, TMS, and other private-pay treatments.

The same request and review process may apply when the denial concerns mental-health or substance-use care. The treatment name alone does not establish coverage: the plan may raise medical necessity, a benefit exclusion, or another reason. Keep the exact denial and your clinician's supporting explanation so you can ask for review of the decision actually made.

Parity is a self-help document-preparation tool, not a law firm. It does not give legal advice or promise a coverage decision.