Single Case Agreement 101 is designed to help you understand how these special contracts between an insurance company and an out-of-network provider work. A Single Case Agreement (SCA) is a one-time contract that enables a patient to receive medical services from a provider outside their provider network while still using in-network benefits. It usually applies to a specific client for a designated length of time at an agreed rate, ensuring access to essential healthcare services without major financial strain.
These contractual agreements play a key role in healthcare coverage, helping payers and providers manage service delivery and payment terms. Although negotiating these case-basis rates can be challenging, they allow for flexible coverage periods and rate negotiation between insurance payers and medical providers, resulting in smoother payment processing and fairer reimbursement rates.
When would a patient need a Single Case Agreement?
A patient might need a Single Case Agreement when they require a specialized service unavailable from an in-network provider within a reasonable amount of time or proximity. This can occur due to a lack of availability, a recent insurance transition, or the need for ongoing treatment with a specific provider.
Sometimes, an out-of-network outpatient provider or treatment program may have a clinical specialty that best suits the patient’s unique needs, such as specific age, gender, or religious preference. In some cases, continuity of care is vital when a patient is stepping down to a different level of care in the same facility.
Medical necessity, specialized care, and clinical expertise are strong qualification criteria for these agreements. They help overcome provider shortages, location barriers, or capacity constraints, ensuring care continuity and preventing treatment disruptions that could cause harm or affect patient safety.
Why would a provider want a Single Case Agreement?
A provider may pursue a Single Case Agreement to continue working with a patient who has switched insurance plans and is now out-of-network. This transitional period helps maintain continuity of care until contracting with the new network is completed.
Financially, SCAs often offer comparable or better rates than standard in-network rates, making them attractive from a provider compensation and business strategy perspective. Beyond reimbursement rates, they support patient retention, therapeutic relationships, and care continuity, providing both financial stability and practice sustainability.
These temporary arrangements can bridge the gap during network transitions, ensuring provider participation without interrupting the treatment relationship.
What else do I need to know about Single Case Agreements?
When navigating insurance, an SCA can be a helpful alternative for patients and guardians. However, it requires a strong justification that explains why a specific provider is better qualified to meet certain medical needs than those within the in-network care options.
Supporting evidence such as extended wait times, geographic distance, or lack of specialized providers strengthens an SCA request. Detailed documentation—including medical rationale, provider qualifications, and treatment justification—is essential to demonstrate clinical necessity and ensure approval.
A well-prepared justification process improves approval chances by showing care standards, treatment adequacy, and adherence to insurance documentation requirements. This ensures that patients gain timely access to qualified providers and adequate care despite insurance barriers.
How To Request a Single Case Agreement
The process begins with contacting Member Services at your insurance company (you’ll find the number on your insurance card). Ask for in-network providers that offer the needed specialty. If none are available, inquire about your out-of-network benefits (OON benefits) and whether an in-network rate can be authorized under an SCA.
Next, request to be connected with a Behavioral Health Case Manager—your advocate and main point of contact for managing case assignment and insurance negotiation. Explain that you have exhausted all resources, and provide clear documentation of facility availability or provider shortages.
Your chosen provider or treatment center can then work with your insurance payer to establish the agreement. Outpatient providers such as your therapist, dietitian, or psychiatrist can also contribute clinical rationale to strengthen your request.
Once approved, confirm the service delivery, duration, payment terms, and ensure there are contingency plans in case of denial. While the process can involve administrative preparation and possible delays, thorough coordination improves your success rate and helps secure timely access to treatment services.
If a provider can be granted Single Case Agreements, why would they want to become in-network providers?
While SCAs offer flexibility, insurance companies typically rely on a pool of contracted providers within a geographic area. When enough providers are available, a payer may not offer SCAs. For government insurance such as Medicaid, in-network benefits are the only option, making SCAs less likely.
For smaller practices, selective contracting allows them to focus on high-value partnerships. However, payment processing, out-of-network claims, and administrative challenges can be time-consuming. Reimbursement timelines may extend due to documentation requirements or payer behavior, making in-network participation a more stable long-term strategy.
By evaluating practice management, financial stability, and cash flow, providers can decide whether network inclusion or selective contracting best fits their business strategy and sustainability planning.
Single Case Agreements With Medicaid and Medicare
Medicaid plans often require SCAs due to network limitations or no in-network options. This is common for residential level-of-care where specialized facilities are limited. Conversely, traditional Medicare typically does not allow SCAs, though Medicare Advantage plans sometimes grant gap exceptions.
These approval processes can be more complex than with private insurance, as government programs have stricter coverage restrictions and benefit limitations. However, under the right exception process, patients may still secure access to treatment options and residential services otherwise unavailable within their network coverage.
Obtain Compensation for Single Case Agreements With Zanexmed
Managing SCAs can be challenging for providers due to complex rate negotiation, billing documentation, and reimbursement processes. Zanexmed simplifies this by offering expert guidance, administrative support, and payment assistance.
Our team specializes in provider compensation, rate consulting, and insurance contracting, ensuring you receive fair and timely payments for your applied services. We handle clinical documentation, manage billing resources, and navigate insurance negotiation, allowing you to stay focused on patient care while we take care of your financial and operational needs.
👉 Partner with Zanexmed today to streamline your Single Case Agreement process and ensure your practice receives the reimbursement it deserves.