SCAN Health Plan for Behavioral Health

• SH
• Medicare Advantage

SCAN Health Plan

SCAN Health Plan is a nonprofit Medicare Advantage organization serving CA, AZ, NV, NM, and TX. Provider guide for behavioral health credentialing and billing.

Quick Reference

Payer Type

Medicare Advantage

Parent Company

SCAN Group (nonprofit)

Headquarters

Long Beach, CA

Provider Portal

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Portal Guide

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Credentialing

CAQH ProView (primary) with SCAN provider enrollment application

Timeline

60-90 days from completed application

Coverage

5 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

10 min

Covered Levels of Care

• Inpatient Psychiatric Hospitalization
• Partial Hospitalization Program (PHP)
• Intensive Outpatient Program (IOP)
• Outpatient Mental Health and SUD Treatment
• Medication-Assisted Treatment (MAT)

Medical Necessity Criteria

• CMS Medicare Advantage medical necessity standards
• ASAM Criteria (for SUD level of care placement)
• SCAN proprietary clinical review guidelines
• InterQual or equivalent criteria for inpatient psychiatric admissions

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Overview

SCAN Health Plan is a nonprofit Medicare Advantage organization headquartered in Long Beach, California. Founded in 1977 as a senior services organization, SCAN (Senior Care Action Network) expanded into managed care and has grown into one of the largest nonprofit Medicare Advantage plans in the western United States. As of 2025, SCAN serves approximately 270,000–285,000 Medicare Advantage members across its five-state footprint of California, Arizona, Nevada, New Mexico, and Texas. SCAN operates under the SCAN Group, a nonprofit holding company, and is not affiliated with the SCAN Foundation despite the shared historical name origin.

SCAN’s mission centers on helping seniors stay healthy and independent, with an emphasis on care management, social determinants of health, and preventive services for its largely senior and dual-eligible member population. For behavioral health providers, SCAN represents a payer that combines the CMS Medicare Advantage regulatory framework with the operational characteristics of a regional nonprofit — including a comparatively focused geographic footprint, a member demographic that skews older with higher behavioral health comorbidity rates, and plan designs that often include enhanced supplemental benefits beyond Original Medicare.

As a Medicare Advantage plan, SCAN’s behavioral health operations differ in important ways from commercial payer interactions. SCAN follows CMS-mandated coverage requirements, uses the five-level CMS Medicare appeals process, and adheres to federal timely-filing rules for non-contracted claims. Providers who already work with Original Medicare should treat SCAN as a separate payer requiring independent credentialing, separate authorization workflows, and distinct claims routing.

Behavioral Health Coverage

SCAN Health Plan covers behavioral health services in alignment with CMS Medicare Advantage requirements, with potential supplemental enhancements that may vary by plan year and specific SCAN plan product. Core covered behavioral health services include:

Notable coverage limitation: Medicare Advantage plans, including SCAN, generally do not cover freestanding residential substance use disorder treatment programs. This is an inherent gap in the Medicare benefit structure that has not been closed by CMS rule as of 2025. Members needing residential SUD care may be eligible through Medi-Cal (for dual-eligible members in California) or through supplemental insurance. Verify current SCAN benefit enhancements and any supplemental SUD coverage with SCAN provider services.

Medical necessity for behavioral health services is assessed against CMS Medicare Advantage standards, SCAN’s clinical review guidelines, and for SUD admissions, ASAM Criteria. All behavioral health services subject to utilization management require documentation demonstrating that the requested level of care is medically necessary, that a lower level of care would be clinically insufficient, and that the treatment plan includes active, goal-directed programming.

Federal mental health parity law (MHPAEA) applies to Medicare Advantage plans as of 2025 implementation rules. SCAN, as a Medicare Advantage plan, must ensure that behavioral health benefits are not subject to more restrictive non-quantitative treatment limitations than those applied to medical and surgical services.

• Inpatient psychiatric hospitalization — in Medicare-certified acute psychiatric units and inpatient psychiatric facilities (IPFs), subject to the CMS 190-day lifetime limit for freestanding IPFs
• Partial hospitalization programs (PHP) — Medicare Part B–equivalent PHP benefit, covering active psychiatric and SUD treatment in a structured day program when inpatient care would otherwise be required
• Intensive outpatient programs (IOP) — covered as a Medicare Part B benefit beginning 2024, when IOP became a distinct recognized benefit level under CMS rules
• Outpatient mental health and substance use disorder treatment — individual and group psychotherapy, medication management, psychological testing, and counseling services
• Medication-assisted treatment (MAT) — coverage follows CMS rules, including the OTP bundled payment for methadone (must be delivered by a SAMHSA-certified and Medicare-enrolled OTP), and buprenorphine and naltrexone through Part D pharmacy or Part B office-based administration

Credentialing and Provider Enrollment

SCAN Health Plan uses CAQH ProView as the primary data source for provider credentialing. Providers seeking to join the SCAN network should maintain a fully attested, current CAQH ProView profile before initiating the application. The typical credentialing timeline is approximately 60 to 90 days from submission of a complete application, though timelines can vary based on application volume and completeness.

To initiate credentialing, contact SCAN’s provider relations team or visit the provider section of scanhealthplan.com ↗ to check network availability in your service area and specialty. SCAN evaluates network adequacy by county and specialty, and acceptance of new providers depends on network need in the relevant geographic area.

For facility credentialing, SCAN typically requires:

Note that Medicare Advantage providers are subject to a CMS rule requiring that contracted providers maintain enrollment in Original Medicare through PECOS. Providers who are not enrolled in Medicare FFS cannot contract with Medicare Advantage plans, including SCAN. If you are not yet enrolled in Medicare, initiate the PECOS enrollment process concurrently with the SCAN credentialing application.

Recredentialing generally occurs on a three-year cycle. Maintain your CAQH ProView attestation every 120 days to avoid gaps in credentialing eligibility.

• Current state behavioral health facility license
• Accreditation documentation (Joint Commission, CARF, or state equivalent)
• Medicare certification (or enrollment in PECOS) — because SCAN is a Medicare Advantage plan, providers should generally be enrolled in Medicare through PECOS as a prerequisite or concurrent step
• Organizational NPI and Tax ID / W-9
• Professional liability insurance at required coverage levels
• Program description including levels of care, staffing, and clinical protocols

Verification of Benefits (VOB)

Benefits verification for SCAN Health Plan members should be performed through the SCAN provider portal at scanhealthplan.com/providers ↗ or via standard HIPAA 270/271 electronic eligibility transactions through your clearinghouse. Verify the following for each SCAN member:

Because SCAN members are Medicare beneficiaries, verify that the member does not have a separate Medigap policy (unusual but possible in limited scenarios) or other supplemental coverage that may pay secondary.

• Active enrollment in a SCAN Medicare Advantage plan (confirm plan year, plan product, and effective dates)
• Behavioral health benefits — confirm covered levels of care, any visit or day limits, and whether SCAN uses a behavioral health carve-out manager or manages BH internally
• Dual-eligibility status — many SCAN members are dual-eligible for both Medicare (SCAN covers) and Medi-Cal (California Medicaid) or another state Medicaid program. Dual-eligible members may have supplemental Medicaid coverage for services not covered by SCAN, such as residential SUD treatment
• Deductible and cost-sharing — Medicare Advantage plans have their own cost-sharing structures that differ from Original Medicare
• Prior authorization requirements — confirm which services require authorization for the specific SCAN plan the member is enrolled in

Prior Authorization Requirements

As a Medicare Advantage plan, SCAN Health Plan requires prior authorization for most behavioral health services beyond standard outpatient therapy. Authorization requirements follow CMS Medicare Advantage guidelines and SCAN’s plan-specific utilization management program.

Services typically requiring prior authorization:

Services that may not require authorization:

Submit authorization requests through the SCAN provider portal. Required clinical documentation typically includes: CMS-appropriate diagnosis (DSM-5), presenting symptoms and clinical history, current functional status, rationale for the requested level of care, and documentation that less intensive treatment has been tried or would be clinically insufficient. For SUD admissions, address the relevant ASAM Criteria dimensions in the clinical narrative.

CMS-mandated authorization timelines that SCAN must observe:

Concurrent review is required for all authorized inpatient and residential-equivalent behavioral health admissions. Review frequency is typically approximately every 3 to 7 days depending on clinical progress and level of care. Provide updated clinical documentation demonstrating active treatment, medical necessity, and discharge planning at each concurrent review.

If an authorization request is denied, providers can request a peer-to-peer review with a SCAN medical director before filing a formal appeal.

• Inpatient psychiatric hospitalization (pre-admission or immediate notification for emergency admissions)
• Partial hospitalization programs (PHP)
• Intensive outpatient programs (IOP)
• Medically managed or medically monitored detoxification services
• Opioid treatment program (OTP) enrollment

• Standard outpatient psychotherapy and psychiatric medication management (verify by plan product)

• Standard (non-urgent) authorization requests: determination within 14 calendar days
• Expedited (urgent) authorization requests: determination within 72 hours

Claims and Billing

SCAN Health Plan is a Medicare Advantage plan with its own payer ID, separate from CMS’s Medicare FFS payer. Do not route SCAN claims to your Medicare Administrative Contractor (MAC) — they must go to SCAN directly via its designated claims address or electronic payer ID.

Claim formats:

Timely filing:

Claims submitted after the applicable timely filing deadline are denied without standard appeal rights. Submit claims promptly and track submission dates carefully.

Common denial reasons for behavioral health claims with SCAN:

CMS Five-Level Appeals Process

As a Medicare Advantage plan, SCAN is governed by the five-level CMS Medicare appeals framework for both coverage and payment disputes:

Filing deadlines are strictly enforced at each level. Missing a deadline without good cause generally forfeits appeal rights at that level. Submit appeals with complete clinical documentation addressing the specific denial reason, and always reference the denial notice number.

• Institutional claims (inpatient psychiatric, PHP, IOP when billed institutionally): UB-04 / 837I
• Professional claims (outpatient psychotherapy, medication management): CMS-1500 / 837P

• Contracted providers: per your SCAN provider agreement — most commonly 90 days from date of service (verify your contract)
• Non-contracted providers: 1 calendar year from the date of service, per CMS Medicare Advantage rules

• Missing or expired prior authorization
• Authorization number not included on the claim
• Claim submitted to Medicare FFS MAC rather than to SCAN (routing error)
• Diagnosis code not matching authorized service
• Revenue code or CPT code inconsistent with the authorized level of care
• Provider not credentialed with SCAN (or Medicare enrollment lapsed)
• Services rendered outside SCAN’s service area

• Redetermination — SCAN reviews the denial; must be filed within 60 days of the initial denial notice
• Reconsideration — reviewed by a CMS-contracted Qualified Independent Contractor (QIC); must be filed within 180 days of the Redetermination decision
• Administrative Law Judge (ALJ) hearing — before the HHS Office of Medicare Hearings and Appeals; must meet the minimum amount-in-controversy threshold ($180 in 2025, adjusted annually)
• Medicare Appeals Council (MAC) review — discretionary review by the Departmental Appeals Board
• Federal district court — judicial review if the federal threshold is met

Key Contact Information

• Provider Portal: scanhealthplan.com/providers ↗
• Credentialing: CAQH ProView + SCAN provider enrollment — contact SCAN provider relations via the provider portal for current credentialing instructions
• Prior Authorization: Submit through the SCAN provider portal; contact SCAN utilization management for urgent or expedited requests
• Verification of Benefits: SCAN provider portal or EDI 270/271 via clearinghouse
• Claims Submission: Electronic via clearinghouse using the SCAN Health Plan payer ID (confirm current payer ID with your clearinghouse or SCAN)
• Appeals: Follow the five-level CMS MA appeals process; contact information on denial notices
• Medicare PECOS Enrollment (prerequisite): pecos.cms.hhs.gov ↗
• SCAN Headquarters: Long Beach, CA

Frequently Asked Questions

SCAN Health Plan is headquartered in Long Beach, California, and operates as a Medicare Advantage plan in California, Arizona, Nevada, New Mexico, and Texas as of 2025. SCAN is one of the largest nonprofit Medicare Advantage organizations in the western United States, serving a predominantly senior and dual-eligible member population. SCAN is affiliated with the SCAN Group, a nonprofit holding company, but is not related to the SCAN Foundation despite sharing a common historical name lineage. Network needs and credentialing acceptance vary by service area and specialty — contact SCAN provider relations to confirm whether your geographic area has current network openings.

As a Medicare Advantage plan, SCAN Health Plan requires prior authorization for most behavioral health services beyond standard outpatient therapy. Inpatient psychiatric hospitalization, partial hospitalization programs (PHP), and intensive outpatient programs (IOP) generally require pre-admission or admission-day authorization. Submit authorization requests through the SCAN provider portal at scanhealthplan.com/providers. Clinical documentation should address CMS Medicare Advantage medical necessity standards and, for SUD admissions, should speak to ASAM Criteria dimensions. Concurrent reviews apply for continued stay authorization. SCAN follows CMS-required timeframes for authorization decisions: 72 hours for urgent requests and 14 calendar days for standard requests.

For contracted (in-network) providers, the timely filing deadline for SCAN Health Plan claims is generally set by the provider agreement — most SCAN provider contracts specify 90 days from the date of service, though this can vary by contract. For non-contracted providers, CMS rules apply: the timely filing window for Medicare Advantage claims is one calendar year from the date of service, per CMS regulations. Claims submitted after the applicable timely filing deadline are denied and generally do not have appeal rights, so prompt submission is strongly recommended. Always confirm your specific contracted deadline by reviewing your SCAN provider agreement.

As a Medicare Advantage plan, SCAN Health Plan is governed by the CMS five-level Medicare appeals framework. The five levels are: (1) Redetermination by SCAN Health Plan; (2) Reconsideration by a Qualified Independent Contractor (QIC); (3) Administrative Law Judge (ALJ) hearing before the Office of Medicare Hearings and Appeals (OMHA); (4) Medicare Appeals Council (MAC) review; and (5) Federal district court review. Each level has specific filing deadlines established in the denial notice and by CMS regulation — missing a deadline generally forfeits the appeal right at that level. Expedited appeals are available for situations involving urgent medical needs. Providers should submit appeals through the SCAN provider portal with supporting clinical documentation.

SCAN Health Plan, as a Medicare Advantage plan, follows CMS coverage rules for behavioral health services, which means coverage generally mirrors what Original Medicare covers with any plan-specific enhancements. Original Medicare does not cover freestanding residential substance use disorder treatment (this is a notable gap in both Original Medicare and most Medicare Advantage plans). SCAN's Medicare Advantage benefit may include enhanced behavioral health benefits beyond Original Medicare for certain outpatient services, but freestanding residential SUD treatment is generally not a covered benefit. Inpatient psychiatric hospitalization in a Medicare-certified facility is covered, subject to the 190-day lifetime limit for freestanding psychiatric hospitals under Original Medicare rules that CMS applies to MA plans. Contact SCAN directly to verify current benefit enhancements and any supplemental coverage for behavioral health that SCAN has added to its standard CMS benefit.

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This guide is provided for informational purposes only and does not constitute legal, regulatory, or professional advice. Payer requirements, phone numbers, and portal URLs are subject to change. Always verify current information directly with the payer. is not affiliated with the insurance companies described on this page.

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Official sources

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