.png)
The Complete Guide to Single-Case Agreements for Medical Providers
- Veronica Cruz
- Oct 1
- 12 min read
Updated: Oct 2
When a patient desperately needs your specialized care but their insurance plan doesn't include you in their network, what happens next? For many providers, this scenario means turning away someone who specifically sought out your expertise.
But there's a powerful solution that too few practices understand or utilize effectively: the single-case agreement.
A single case agreement can transform an impossible situation into a viable path forward. It's the bridge that connects patients to the care they need while ensuring you receive fair compensation for your services. Yet despite its importance, the process remains mysterious to many providers, buried in insurance jargon and inconsistent procedures across payers.
This comprehensive guide will demystify single case agreements from start to finish. Whether you're an ABA therapist, physical therapist, mental health provider, or any other specialty practitioner facing out-of-network challenges, you'll learn exactly how to request, negotiate, and successfully bill under these agreements.
Inside this Article
What Is a Single-Case Agreement in Insurance?
A single-case agreement (SCA) is a short-term contract between a health insurance company and a provider who isn’t part of the plan’s network. It’s designed for one patient, one provider, and one specific medical need. SCAs are most often used when the care a patient requires isn’t available through in-network options. They also come into play if a patient changes insurance carriers and suddenly finds their trusted provider out of network, or when the closest in-network option is too far away to be practical.
Why Single-Case Agreements Are Important in Healthcare
Single case agreement insurance plays a critical role in patient access. They allow people to continue treatment with the right provider instead of being forced to settle for limited or delayed care. For patients who need specialized therapy or urgent services, an SCA can make the difference between getting timely treatment and facing harmful interruptions. From a provider’s standpoint, SCAs reduce the risk of claim denials in revenue cycle management and create a pathway to fair compensation for out-of-network services. For insurers, they help maintain compliance with network adequacy requirements and improve member satisfaction.
Single-Case Agreements vs. Standard Insurance Contracts
It’s easy to confuse single case agreement insurance with regular network agreements, but they’re not the same. A standard insurance agreement applies across the board to all members in the plan, with rates and rules already negotiated. By contrast, a single-case agreement is a one-off arrangement with customized terms, rates, and conditions specific to a single patient’s situation. This flexibility allows providers and insurers to set reimbursement amounts that reflect the unique circumstances of the case rather than being bound to preset in-network rates.
Key Points to Remember About SCAs
They authorize care with out-of-network providers when no suitable in-network option exists.
They act as a replacement for prior authorization in situations where no contract is in place.
Terms—including rates, length of coverage, and services approved—vary for each patient.
Reimbursement is negotiable, since the agreement isn’t tied to in-network fee schedules.
Not sure if a single-case agreement is the right option for you? This blog breaks it down.
When Are Single-Case Agreements Typically Needed?
Single-case agreements (SCAs) step in when patients cannot reasonably access care through their health plan’s existing network. These agreements are not casual workarounds—they are designed for situations where network limitations, clinical urgency, or continuity of care demand an exception.
As Tad Molden, Clinical Director at Cube Therapy Billing, explains:
“An out-of-network provider doesn’t have a formal contract with the payer, so they can’t secure a standard prior authorization. The single-case agreement becomes that substitute—it’s how patients still get access to critical care, and
how providers get properly reimbursed.”
Below are the most common scenarios where an SCA request is appropriate.
1. When the Provider Is Out-of-Network
Sometimes providers choose not to join certain networks—either because the payer is small, reimbursement rates are unsustainable, or they rarely see patients from that plan. If a patient insured by such a plan seeks services, the only way forward may be through an SCA. Insurers are often reluctant in these cases since their incentive is low, but strong documentation of medical necessity can help secure approval.
2. No In-Network Specialists Available
One of the strongest justifications for an SCA is the absence of in-network providers offering the required specialty. This is especially common with Medicaid and Medicare populations, where networks can be thin and specialists are limited. ABA therapy, trauma-focused care, or complex behavioral health services often fall into this category.
3. Services or Treatments Not Offered In-Network
There are cases where the insurance network has providers, but specific treatment types are missing. Examples include addiction recovery programs, eating disorder clinics, or group and family counseling. If a plan cannot meet the clinical need through its contracted providers, an SCA is the bridge to family financial responsibilities.
4. Patient Preferences Based on Age, Gender, or Religious Needs
Patients may require care from providers who align with their cultural, religious, or gender-based preferences—especially in sensitive treatment areas. Pediatric and geriatric populations are also examples where expertise is not interchangeable, making an SCA the right approach to ensure appropriate, effective care.
5. Credentialing Delays
Credentialing new providers can take 90–120 days, leaving patients in limbo. If a provider is in the process of becoming in-network but the patient cannot wait for approval, an SCA allows care to begin immediately. As Tad notes:
“When a child urgently needs therapy, insurers often approve the SCA. They recognize the provider is already moving through credentialing and don’t want to delay care.”
6. Insurance Carrier Changes
Coverage disruptions often happen when families switch insurance during open enrollment or job transitions. If the current provider is suddenly out-of-network, an SCA maintains continuity of care. Consider this scenario: A child has been receiving ABA therapy for months. In December, the family had coverage through Plan X, which included the provider in-network. In January, they moved to Plan Y, where the provider is out-of-network. Without an SCA, care would stop. With one, treatment continues seamlessly—avoiding regression in progress and protecting the therapeutic relationship.
7. Geographic Barriers
Even when insurers list in-network providers, those providers may be located too far away to be practical. If the nearest option requires long commutes—an hour or more each way, for example—an SCA can be justified to cover a closer out-of-network provider. This is especially important for therapies requiring multiple visits per week, such as ABA or physical rehabilitation.
Why These Situations Matter
Each of these scenarios demonstrates the core principle behind SCAs: patients should not lose access to medically necessary care simply because of network design flaws or administrative bottlenecks. By documenting the clinical necessity and proving that no adequate in-network alternative exists, providers can use SCAs to secure approvals that protect both the patient’s health outcomes and the practice’s financial sustainability.
How to Request a Single Case Agreement: Step-by-Step Guide for Providers
Why Providers Benefit from Single-Case Agreements
For healthcare providers, single-case agreements (SCAs) are more than just an administrative tool—they are a way to protect patient access while ensuring financial sustainability.
One of the biggest advantages is that SCAs reduce denials tied to out-of-network claims. Instead of fighting costly appeals after services are delivered, providers secure approval upfront. This makes billing and reimbursement far more predictable.
Another major benefit lies in the ability to negotiate reimbursement rates. Unlike standard network contracts, SCAs are not bound by preset fee schedules. Providers can propose rates that reflect their expertise, outcomes, and overhead costs. As Tad Molden, Chief Operating Officer at Cube Therapy Billing, explains:
“With a single-case agreement, clinicians can request reimbursement that reflects the true value of their services, rather than being locked into restrictive in-network rates.”
This flexibility often translates into significant financial improvement. Tad notes that in many cases, providers are able to negotiate rates 30–50% higher than the standard in-network amount, which helps them sustain quality care without compromising financial stability.
Over time, successful SCA negotiations can also strengthen relationships with payers. By demonstrating professionalism and compliance, providers improve their standing with insurers—sometimes paving the way for future network participation.
For practices awaiting credentialing approval, SCAs offer an immediate path to begin treating patients. This means providers don’t have to wait months to build their caseloads—they can care for patients right away while establishing a payer relationship.
Why Insurance Carriers Use Single-Case Agreements
From the insurer’s perspective, SCAs solve a different set of problems. These agreements allow carriers to maintain member satisfaction and retention when their networks fall short. Without an SCA, patients may be forced to switch plans or delay care—outcomes that frustrate members and damage trust.
SCAs also help carriers avoid disputes and appeals. Instead of facing repeated calls, grievances, or even state regulatory challenges, payers resolve the issue with a one-time agreement. Checking insurance before requesting SCAs is a must to avoid rejections
Operationally, SCAs are efficient. Unlike ongoing prior authorizations or repeated exception requests, a single-case agreement is negotiated once and then applied consistently to claims for the defined period. This saves insurers' administrative time while reducing friction with both patients and providers.
In essence, SCAs are a win–win mechanism. Patients get timely access to care, providers receive fair reimbursement, and insurers demonstrate responsiveness without having to overhaul their networks.
How the Single-Case Agreement Process Works
A single-case agreement (SCA) is not just paperwork—it’s a coordinated effort between the patient, provider, and insurance company to ensure access to medically necessary care when in-network options aren’t available.
At its core, the process begins when a patient seeks services from an out-of-network provider. The provider then contacts the patient’s insurance company to request coverage under a special agreement. Whether the request is approved depends on the circumstances and how well the case is documented.
For example, take this real-world scenario:
“I have a family who is currently paying out-of-pocket for child therapy sessions (I have a private pay practice), and they are interested in setting up a single case agreement through their insurance provider in order to pay less for my sessions. Does anyone know of any potential drawbacks to this type of arrangement?”
This kind of situation is exactly where an SCA comes into play. The family wants to continue working with their current provider, but since the provider is out-of-network, they’re looking to shift some of the financial burden onto insurance. In practice, the SCA would allow the insurer to treat that provider as in-network for just this one case.
The main drawbacks? First, reimbursement rates are usually lower than private pay, so the provider may take a pay cut. Second, payment comes on the insurance company’s timeline, which often means delays of 30–60 days compared to immediate private pay. Third, there’s more administrative work—progress notes, treatment plans, and sometimes repeated authorizations. And finally, these agreements are temporary. If the insurer decides there’s an in-network provider available, they can end the agreement, leaving the family back at square one.
So while an SCA can absolutely make therapy more affordable for families, providers need to weigh the reduced pay, slower cash flow, and added paperwork against the benefit of keeping care accessible for the client.
Step 1: Initiating the Request
The healthcare provider typically initiates the SCA by reaching out to the payer’s provider services department. The request can start with a phone call, but it usually requires a formal submission—either through a dedicated form, a provider portal, or a letter of medical necessity.
Tad Molden, Clinical Director at Cube Therapy Billing, explains:
“In ABA therapy, for example, new patients often require an initial assessment before treatment begins. Normally, this step requires prior authorization—but since out-of-network providers can’t obtain that, an SCA request is the correct substitute.”
This initial submission establishes the medical necessity of care, outlines the access problem (such as a lack of in-network providers or long wait times), and begins the negotiation process.
Step 2: Review by the Insurance Company
Once submitted, the payer reviews the request. Their decision often depends on:
Why the provider is out-of-network (e.g., awaiting credentialing vs. permanently non-participating).
Network adequacy (are there truly no reasonable in-network options?).
Medical necessity (is the requested service clinically justified and time-sensitive?).
Insurance carriers are more likely to approve when credentialing delays are the main barrier. As Tad notes:
“If the insurer sees that you’ve applied for network participation and their processing time is the bottleneck, they usually won’t deny. They know the provider will eventually be in-network, and they don’t want the patient’s care delayed in the meantime.”
Step 3: Negotiating Terms
If the insurer agrees in principle, the provider and payer then negotiate service coverage, CPT codes, and reimbursement rates. Unlike in-network contracts, SCAs allow room for flexibility.
For example, rates may be set closer to the provider’s usual and customary fees rather than fixed network rates. The provider also confirms treatment frequency, duration, and any limitations (such as unit caps or visit maximums).
When the SCA applies to an existing patient, the provider ensures the patient has given informed consent for both the treatment plan and financial responsibilities.
Step 4: Finalizing and Billing
Once the agreement is formalized, the insurance company issues written approval that includes:
Patient and provider details
Authorized CPT codes and units
Approved reimbursement rates
Effective start and end dates
Any reference or authorization numbers
With this document in hand, providers can begin ABA billing claims. Claims are submitted using the standard CMS-1500 form, with the SCA reference number included in Box 19 to ensure proper adjudication.
The insurer then reimburses at the negotiated rate, while the patient remains responsible for applicable deductibles or co-pays—just as they would under normal benefit rules.
Single-Case Agreement Billing and Reimbursement
Once a single-case agreement (SCA) is approved, the next step is proper billing. Accuracy at this stage is critical—any mistakes can delay or reduce reimbursement.
Submitting Claims Under an SCA
Providers bill for services under an SCA using the CMS-1500 claim form (also known as the 1500 Claim Form). The billing follows the negotiated rates outlined in the agreement, which are often more favorable than standard out-of-network rates.
Insurers require CPT codes and modifiers to ensure proper payment. As Tad Molden, Clinical Director at Cube Therapy Billing, explains:
“The coding rules don’t change under a single-case agreement—you still use the payer’s or state-specific CPT coding guidelines. The difference is in authorization. Instead of prior authorization, you enter the SCA number in Box 19 of the claim form, formatted as ‘SCA – Ref # [reference number].’ This ensures the payer routes your claim correctly.”
Timely filing is key. Submitting claims promptly gives providers more time to resolve errors or disputes if they arise.
Handling Denials and Appeals
Even with an SCA in place, denials can occur. The most common reasons include:
Missing or incorrect CPT codes or modifiers.
Failure to reference the SCA number properly.
Incomplete documentation.
If a claim is denied, providers should be ready to appeal quickly. Each payer and state has unique appeal requirements, so it’s essential to follow their guidelines carefully. Supporting documents—such as the signed SCA, treatment notes, and patient consent—strengthen the appeal.
In situations where an SCA is denied outright, Tad emphasizes the importance of communication with families:
“If insurance won’t approve the SCA, the responsibility shifts. Families often need to call the payer directly and explain why the exception is medically necessary. If that fails, the only option left is private pay.”
Best Practices for Billing and Managing SCAs
To maximize reimbursement and minimize errors, providers should follow structured best practices:
Track All Agreements – Use a spreadsheet or practice management system to log approval dates, expiration, CPT codes, and rates.
Define Services Clearly – Specify services in the agreement to avoid confusion or underpayment.
Stay Compliant – SCAs are legally binding. Both providers and insurers must follow the agreed terms.
Understand Legal Obligations – Providers must remain within their scope of practice, while insurers must cover services delivered under the contract.
Document Everything – Maintain organized copies of agreements, forms, emails, and appeals.
Limitations of Single-Case Agreements
While SCAs create access to care, they come with limitations:
Cost Transparency – SCAs follow fee-for-service models. Some treatments or medications may not be covered, leaving patients with higher costs. Fortunately, the No Surprises Act protects patients with commercial insurance from excessive balance ABA billing.
Quality Evaluation – Because SCAs are often arranged quickly, payers may not fully assess the provider’s quality or facility standards.
Lack of Wraparound Services – Unlike larger network programs, SCAs usually don’t cover additional supports such as case management or counseling, which can increase stress for families.
FAQs
What does SCA stand for in insurance?
In insurance, SCA stands for Single-Case Agreement. It’s a special contract that allows a patient to see an out-of-network provider when in-network options are unavailable or inadequate. Instead of forcing the patient to switch doctors or travel long distances, the insurer approves this one-time exception so the patient gets the care they need, and the provider is paid at a negotiated rate.
What is an SCA agreement?
An SCA agreement is essentially a bridge between an out-of-network provider and an insurance company for a specific patient. It spells out which services are covered, how long the approval lasts, and exactly what the reimbursement rate will be. Unlike a standard prior authorization, which applies to in-network care, an SCA creates a custom pathway that ensures the patient can access treatment without having to wait for full credentialing or switch providers mid-care.
What is a single contract agreement?
A single contract agreement is another way some people describe a Single-Case Agreement (SCA) in healthcare. It refers to a one-off contract between an insurance plan and an out-of-network provider for a single patient’s care. While “single contract agreement” can mean different things in business, in the insurance context, it almost always points to SCAs—temporary, case-specific arrangements designed to close gaps in patient access.
What is the purpose of a single case agreement?
The purpose of a single-case agreement is simple: make sure patients don’t lose access to necessary care when the right provider isn’t available in-network. SCAs allow insurers to meet their network adequacy requirements while giving families continuity of care. For providers, it means fewer denials and a clear payment arrangement. For patients, it often prevents long delays, unnecessary travel, or the disruption of switching providers mid-treatment.
Streamlining ABA Billing With Cube Therapy Billing
Managing SCAs effectively requires expertise in both negotiation and ABA billing. Many ABA practices struggle with the administrative burden—this is where Cube Therapy Billing comes in.
Our team ensures every step is handled:
Verifying whether a payer accepts single-case agreements.
Preparing and submitting all required paperwork.
Monitoring claims to ensure the SCA terms are applied correctly.
Appealing denials with supporting documentation to secure reimbursement.
As Tad notes:
“The ABA billing process itself doesn’t change—you use the same CPT codes and modifiers. What changes is the payment. With SCAs, reimbursement often exceeds in-network rates, but only if you bill and track them correctly.”
By partnering with Cube Therapy Billing, providers can reduce administrative headaches, secure faster reimbursements, and keep their focus where it matters most: on patient care.