Medical Billing Terms S: Secondary Insurance, Single Case Agreement and SBIRT

Secondary insurance is the plan that may pay after the primary plan has processed a claim. This page defines it with the terms from SAM exclusions to single case agreement, including self-pay, signature on file, SBIRT and the 1915 waivers. MCM South Medical Billing Service, LLC works only in mental and behavioral health billing.

Last reviewed: October 10, 2026Sources linked at each term

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Billing Terms Glossary slide, Terms S: Secondary Insurance - MCM South Medical Billing Service, LLC

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On this page (20 terms)

SAM Exclusions
SAMHSA
SBIRT
Scope of Practice
Screening
Secondary Insurance
Section 1557 (Nondiscrimination in Health Programs)
Section 1915(b) Waiver
Section 1915(c) Waiver
Section 1915(i) State Plan HCBS
Security Risk Analysis
Self-Funded Plan
Self-Pay
Sentinel Event
Serious Mental Illness (SMI)
Shared Savings
Signature on File (SOF)
Significant, Separately Identifiable E/M
SimplePractice
Single Case Agreement (SCA)

How to use these Secondary Insurance definitions

Use this page as a quick reference for Secondary Insurance, from SAM Exclusions to Single Case Agreement (SCA). Each entry gives a plain definition, why it matters to a mental health practice, and an official source. When a rule changes by payer or state, the entry says so, so confirm Secondary Insurance details with the payer before you bill.

Checklist: put the secondary insurance definitions to work

SAM Exclusions: Often checked alongside the OIG list.
SAMHSA: Source for behavioral health program standards and guidance.
SBIRT: Has specific codes in Medicare and some Medicaid programs.
Scope of Practice: Payers may deny services outside a clinician's scope.

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SAM Exclusions

General (all payers)

Also called System for Award Management exclusions; SAM.gov debarment

Definition: A federal database of parties barred from federal contracts and some federal programs.
Why it matters: Often checked alongside the OIG list.
Illustrative example: A practice checks SAM when hiring.

Reference sourceHHS (U.S. Department of Health and Human Services)checked 10/9/26

CategoriesAudits & Compliance

SAMHSA

Medicaid (state-specific)

Also called Substance Abuse and Mental Health Services Administration

Definition: An HHS agency that leads federal efforts on behavioral health, including grants, standards, and confidentiality rules for substance use records.
Why it matters: Source for behavioral health program standards and guidance.
Illustrative example: A program follows SAMHSA guidance on Part 2.

Reference sourceSAMHSAchecked 10/9/26

CategoriesMedicare & Medicaid Terms Behavioral Health Specific Terms

SBIRT

General (all payers)

Also called Screening, Brief Intervention, and Referral to Treatment

Definition: A public health approach to identify people with risky substance use, provide a brief intervention, and refer to treatment when needed.
Why it matters: Has specific codes in Medicare and some Medicaid programs.
Illustrative example: A clinic bills SBIRT using payer-recognized codes.

Reference sourceSAMHSA CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesBehavioral Health Specific Terms

Scope of Practice

General (all payers)

Also called practice authority; independent practice authority

Definition: The services a licensed professional is legally allowed to provide, defined by state law and board rules.
Why it matters: Payers may deny services outside a clinician's scope.
Illustrative example: A state limits which diagnoses a counselor may make.

Reference sourceHHS (U.S. Department of Health and Human Services)checked 10/9/26

CategoriesCredentialing & Enrollment Behavioral Health Specific Terms

Screening

General (all payers)

Also called behavioral health screening; SBIRT

Definition: A brief standardized check to identify possible conditions, such as depression or substance use, which may be billed with specific codes where covered.
Why it matters: Coverage and codes differ by payer and program.
Illustrative example: A primary care office screens for alcohol use with a standard tool.

Reference sourceSAMHSA CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesBehavioral Health Specific Terms

Secondary Insurance

General (all payers)

Also called secondary payer; secondary coverage

Definition: The plan that pays after the primary, typically covering some of what the primary left as patient responsibility, subject to its rules.
Why it matters: Missed secondary billing leaves money uncollected.
Illustrative example: After the primary pays, the practice sends the claim and primary ERA to the secondary.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesEligibility & Benefits Claims Processing

Section 1557 (Nondiscrimination in Health Programs)

General (all payers)

Also called Section 1557; ACA nondiscrimination; language access rule

Definition: Section 1557 of the Affordable Care Act is a federal nondiscrimination provision that applies to certain health programs and activities that receive federal financial assistance. HHS Office for Civil Rights enforces it.
Why it matters: It can require language assistance and notices. Practices that take Medicaid or Medicare may be covered, so ask counsel what applies.
Illustrative example: A practice that accepts Medicaid reviews its notices and its process for language assistance.

Reference sourceHHS (U.S. Department of Health and Human Services)HHS Office for Civil Rights (OCR)checked 10/9/26

CategoriesAudits & Compliance

Section 1915(b) Waiver

Medicaid (state-specific)

Also called 1915(b); managed care waiver

Definition: A Section 1915(b) waiver is a Medicaid waiver that lets a state require enrollment in managed care or limit choice of providers.
Why it matters: Some states run behavioral health through a 1915(b) waiver, which can create a separate behavioral health carve-out network. Check how your state does it.
Illustrative example: A state moves its behavioral health benefit to a separate managed care entity under a 1915(b) waiver.

Reference sourceMedicaid.gov CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Section 1915(c) Waiver

Medicaid (state-specific)

Also called 1915(c); HCBS waiver; home and community-based services waiver

Definition: A Section 1915(c) waiver is a Medicaid waiver that lets a state offer home and community-based services to people who would otherwise need institutional care.
Why it matters: Some behavioral health services, such as supports for people with serious mental illness or developmental needs, are offered through waivers. Eligibility and services vary by state and by waiver.
Illustrative example: A state offers community-based supports through a 1915(c) waiver, and a provider enrolls under that waiver.

Reference sourceMedicaid.gov CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Section 1915(i) State Plan HCBS

Medicaid (state-specific)

Also called 1915(i); state plan home and community-based services

Definition: A Section 1915(i) benefit lets a state offer home and community-based services through its Medicaid state plan instead of through a waiver.
Why it matters: Some states use it for behavioral health supports. Requirements and the services offered differ by state.
Illustrative example: A state offers mental health rehabilitation supports under a 1915(i) state plan option.

Reference sourceMedicaid.gov CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Security Risk Analysis

General (all payers)

Also called HIPAA risk analysis; SRA; security risk assessment

Definition: A security risk analysis is the assessment a covered entity or business associate must do under the HIPAA Security Rule to find risks to the confidentiality, integrity, and availability of electronic protected health information.
Why it matters: It is one of the first things regulators ask for after a breach. Do it, document it, and update it when systems change.
Illustrative example: A practice reviews its EHR, devices, and telehealth tools each year and records its findings.

Reference sourceHHS (U.S. Department of Health and Human Services)HHS Office for Civil Rights (OCR)checked 10/9/26

CategoriesAudits & Compliance EHR & Healthcare Technology Terms

Self-Funded Plan

General (all payers)

Also called self-insured plan; ASO plan; ERISA self-funded

Definition: A plan in which the employer pays claims itself and often hires a payer or TPA to administer it. These plans are typically governed by federal ERISA rules and are not subject to most state insurance mandates.
Why it matters: State mandates and state appeals may not apply, and parity and appeal rights follow federal rules.
Illustrative example: A large employer's plan is administered by a national payer under an administrative services contract.

Reference sourceU.S. Department of Labor, EBSAchecked 10/9/26

CategoriesEligibility & Benefits BCBS, UHC & Commercial Payer Terms

Self-Pay

General (all payers)

Also called private pay; cash pay; out-of-pocket pay

Definition: A patient who pays for services directly rather than through insurance.
Why it matters: Requires fee policies and, for many, a good faith estimate.
Illustrative example: A client chooses to pay $150 per session without using insurance.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesPatient Financial Responsibility Terms

Sentinel Event

General (all payers)

Also called Joint Commission sentinel event; serious safety event

Definition: A sentinel event, as the Joint Commission defines it, is a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm. Suicide of a patient in some settings is one type.
Why it matters: Accredited organizations are expected to review such events and take action. It is a safety and quality term, not a billing term.
Illustrative example: An accredited clinic reviews a serious event and creates a corrective action plan.

Reference sourceThe Joint Commissionchecked 10/9/26

CategoriesQuality & Risk Adjustment Terms Audits & Compliance

Serious Mental Illness (SMI)

Medicaid (state-specific)

Also called SMI; serious mental illness definition; serious emotional disturbance

Definition: Serious mental illness is a term SAMHSA uses for a mental, behavioral, or emotional disorder in an adult that causes serious functional impairment and substantially limits major life activities.
Why it matters: Programs, Medicaid benefits, and some state laws use the term or a similar one. Definitions differ, so check the payer or statute.
Illustrative example: A community clinic checks a patient's diagnosis and functioning against the state's definition to see if a program applies.

Reference sourceSAMHSAchecked 10/9/26

CategoriesBehavioral Health Specific Terms

Shared Savings

General (all payers)

Also called shared savings program; gainsharing

Definition: A payment approach where providers share in savings achieved against a cost target, if quality standards are met.
Why it matters: Tied to quality performance.
Illustrative example: A provider group receives a portion of savings.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesValue-Based Care Terminology

Signature on File (SOF)

General (all payers)

Also called SOF; signature on file; SOF box 12 13

Definition: Signature on File, or SOF, is the notation a practice enters in Box 12 or Box 13 of the 1500 claim form to show it holds the patient's signed release of information or assignment of benefits.
Why it matters: The signed forms must actually be in the record. If a payer audits, it can ask for them.
Illustrative example: A practice enters SOF in Boxes 12 and 13 because the patient signed both authorizations at intake.

Reference sourceNUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)checked 10/9/26

CategoriesClaims Processing Audits & Compliance

Significant, Separately Identifiable E/M

General (all payers)

Also called significant separately identifiable; E/M with psychotherapy; separately identifiable service

Definition: A significant, separately identifiable E/M is an evaluation and management service that goes beyond the usual work of another service billed on the same date and is documented on its own.
Why it matters: Psychotherapy add-on codes need an E/M that is significant and separately identifiable, and the same applies to modifier 25 on some procedures. The note should show the E/M work and the psychotherapy work apart.
Illustrative example: A psychiatrist documents a medication review and a separate 30-minute psychotherapy portion and bills both.

Reference sourceAmerican Medical Association (AMA)CMS Coverage Database, Article A57480 (WPS)checked 10/9/26

CategoriesClaims Processing Behavioral Health Specific Terms

SimplePractice

General (all payers)

Also called Simple Practice

Definition: A vendor of practice management, EHR, telehealth, and billing software for health and wellness practices. Affiliate disclosure: MCM South has an affiliate relationship with SimplePractice and may receive compensation if you sign up through this link.
Why it matters: Widely used by solo and group therapy practices.
Illustrative example: A therapist schedules, documents, and bills from one platform.

Reference sourceSimplePractice (affiliate link)checked 10/9/26

CategoriesEHR & Healthcare Technology Terms

Single Case Agreement (SCA)

General (all payers)

Also called SCA; letter of agreement; LOA; single case rate

Definition: A one-time agreement between a payer and an out-of-network provider to cover a specific member's care at an agreed rate.
Why it matters: It can let a member see a needed provider at in-network cost sharing when no adequate in-network option exists.
Illustrative example: A payer approves an SCA for 12 sessions at a negotiated rate.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesContracting & Network Management Eligibility & Benefits

Quick answer: Secondary Insurance

What is secondary insurance in billing?

Secondary Insurance is the plan that pays after the primary, typically covering some of what the primary left as patient responsibility, subject to its rules. Missed secondary billing leaves money uncollected.

Frequently asked questions: Secondary Insurance

What is a single case agreement?

Single Case Agreement (SCA) is a one-time agreement between a payer and an out-of-network provider to cover a specific member's care at an agreed rate. It can let a member see a needed provider at in-network cost sharing when no adequate in-network option exists.

What does self-pay mean?

Self-Pay is a patient who pays for services directly rather than through insurance. Requires fee policies and, for many, a good faith estimate.

What is signature on file?

Signature on File, or SOF, is the notation a practice enters in Box 12 or Box 13 of the 1500 claim form to show it holds the patient's signed release of information or assignment of benefits. The signed forms must actually be in the record.

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Where MCM South works

MCM South serves psychotherapists and psychiatrists in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.

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