Key Takeaways
- A single case agreement (SCA) is a one-time agreement between an out-of-network therapist and a client's health plan, so that one client can use their in-network benefits with that provider.
- SCAs usually come up when the plan can't offer a suitable in-network provider, or to keep care going when a client's coverage changes.
- An SCA isn't the same as prior authorization. The SCA sets your network status and rate. Prior authorization approves the service itself.
- Get every term in writing before you sign an SCA, including pay rate for each CPT code, which CPT codes can be billed, number of sessions, dates of the agreement, and authorization number.
- Connected documentation (the "golden thread") makes medical necessity much easier to show when working with payors.
- SCAs do not apply to Medicare.
A potential client calls. They've spent months looking for someone who specializes in exactly what you do. You'd be a great fit.
Then comes the challenging part: you're out of network, their budget won’t allow for out of pocket payments, and their plan has no out-of-network benefits.
Before you hand them a referral list, there's one more option worth knowing about. It's called a single case agreement, and it can turn "I can't afford you" into "see you Tuesday."
Below, you'll find what SCAs are, when you can get one, how to request one, what to negotiate, and how to document medical necessity so your request holds up.
What Is a Single Case Agreement?
A single case agreement is a one-time agreement between a health plan and an out-of-network provider to cover one specific client, often for a specified amount of time. For that client, you're paid under the agreement's terms, and the client usually pays their regular in-network cost share, like a copay or coinsurance. (Need a refresher on the lingo? Here's our cheat sheet of insurance terms.)
A few things to know:
- It covers one client. Not your whole caseload.
- It's usually time-limited. Most SCAs have set dates, a set number of sessions, or both.
- It doesn't make you in-network. You're still out of network with the plan for everyone else. If you're thinking about joining, see our guide to insurance paneling for therapists.
Single Case Agreement may also be referred to with related terms like "gap exception" or "network exception." The details vary by plan, so ask what the plan calls it and how it works.
There's also a close cousin called a Transition of Care Agreement. When a client's insurance changes, it may be possible to contract with the new plan for a set number of "transition" sessions, with the goal of finishing treatment or handing the client off to someone in the new network once the agreement ends.
Single Case Agreement vs. Prior Authorization
These two terms get mixed up a lot, and for good reason. They often show up in the same phone call.
Preauthorization, also called prior authorization, is a decision by a health insurer that a service, treatment plan, prescription drug, or durable medical equipment is medically necessary. However, approval does not guarantee coverage.
Here's the quick difference:
Some plans require both. And some SCAs come with their own authorization number, which you'll need on every claim.
When Can Therapists Get a Single Case Agreement?
Plans usually agree to an SCA when they can't offer the client a reasonable in-network option. Common situations include:
- Specialty gap: No in-network provider has the expertise the client needs, like eating disorder treatment or a specific trauma approach.
- Language or cultural fit: The client needs a therapist who speaks their language or understands their identity or community.
- Distance: The nearest in-network, in-person provider is too far away to be realistic.
- Capacity: In-network providers aren't taking new clients or have long waitlists.
- Continuity of care: The client's insurance changed mid-treatment, and switching therapists could set them back.
A client simply preferring you is usually not enough to get a Single Case Agreement. The case is strongest when the plan truly can't meet the client's needs in-network.
Who starts the process? It can be either you or the client, but it often works best when the client calls their plan first. From there, the plan may contact you or the client may give you their contact information so you can request a paperwork packet to complete to begin the process.
How to Request a Single Case Agreement
The process varies by health plan, and approval is not guaranteed. In many cases, the member can start the request, but the insurer and out-of-network provider must agree on the terms.
- Call the health plan. Use the number on the insurance card and ask for the behavioral health department or the team that handles out-of-network exceptions. Ask whether the plan considers single case agreements and what forms or steps it requires.
- Explain why an in-network option may not meet the need. The plan may ask whether an appropriate in-network provider is available, accessible, and able to provide the needed service. Keep a record of providers contacted, wait times, distance, and any relevant specialty limitations.
- Ask the provider to participate. The out-of-network clinician will generally need to share information with the insurer and negotiate the agreement. The clinician may need the member’s written permission to discuss care through a Release of Information.
- Prepare supporting information. The plan may have a packet of paperwork for the clinician to complete that requests information about the clinician’s qualifications, the service being requested, clinical rationale, treatment plan, and relevant records. Share only information needed for the review, with appropriate authorization from the client.
- Clarify the proposed terms. Confirm the procedure codes covered under any contract you receive. Also review the approved dates the contract is valid, the number of sessions approved, payment rate, billing process, and the member’s expected cost-sharing.
- Get the agreement and authorization in writing before starting care. Ask for the effective date, authorization number, and any limits or conditions. Keep copies and confirm how claims should be submitted.
Even when a plan authorizes care, that authorization may not by itself guarantee payment. Confirm the agreement’s terms with both the health plan and the provider before receiving services.
What to Negotiate in a Single Case Agreement
Since an SCA is a one-off agreement, there may be room to negotiate. Plans will likely offer what they pay their network therapists, but you can try to negotiate for more. It helps to know your number going in. Our guide to setting your rates can help.
Beyond the rate, make sure you agree on:
- CPT codes: Which services are covered, like 90791 for the intake and 90837 for 60-minute sessions
- Number of sessions: And whether and how that number can be extended
- Date range: When the agreement starts and ends
- Client cost share: What the client pays per session as a copay or co-insurance
- Authorization number: If there is one and whether you'll need it on every claim
- Billing instructions: Where and how to send claims and anything that should be noted on the claims
Your "Get It in Writing" Checklist
Before you bill, your written agreement should include:
- The payment rate
- Covered CPT codes
- Number of sessions
- Start and end dates
- Authorization number (if applicable)
- Claim submission instructions
- Confirmation of how the plan will process your claims
If anything is missing, ask for an updated copy before you sign the contract or send a claim.
Documenting Medical Necessity for a Single Case Agreement
Plans approve SCAs for care that's medically necessary. HealthCare.gov defines medically necessary as "health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine."
The easiest way to show it is with a strong golden thread in your clinical documentation.
The golden thread is the idea that every piece of documentation connects. Your assessment identifies symptoms. Your diagnosis reflects those symptoms. Your treatment plan identifies the evidence-based interventions you will use to target the symptoms with measurable goals. Your progress notes tell the story of the work you're doing together to work toward those goals and how the client is responding.
When a reviewer opens a client’s chart, they should be able to follow that thread from start to finish without guessing whether the treatment is needed. A few ways to strengthen it:
- Use outcome measures. Scores from tools like the GAD-7 show severity at the start and progress over time.
- Document functional impact. How do symptoms affect work, relationships, sleep, or daily life?
- Connect your expertise to the need. Explain why this client's needs call for your specific training.
- Keep the file ready for extensions. When it's time to renew, you'll need to show both progress and continued need.
Our guide to treatment plans has examples of measurable goals that hold up well.
Keeping your documentation connected takes time. Blueprint's AI-powered EHR helps therapists write session notes faster and track progress over time, so you can spend less time documenting and more time with clients. See how Blueprint works.
Common Single Case Agreement Problems (and How to Avoid Them)
SCAs can be a great tool, but they can come with some headaches:
- Claims get processed as out-of-network anyway. Call the plan with your authorization number and written agreement, and ask for the claims to be reprocessed. Our guide to insurance claim denials covers next steps.
- The agreement quietly expires. Track your end date and session count, and ask for an extension early, typically 4-6 weeks prior.
- Services fall outside the agreement. Stick to the agreed codes, dates, and session count, or get the agreement updated first.
Single Case Agreement FAQ
What is the purpose of a single case agreement?
An SCA lets a client use their in-network benefits with an out-of-network provider when the plan can't offer a suitable in-network option or the client recently changed insurance and changing providers would set them back or prevent them from finishing their course of treatment. It's meant to protect access to appropriate care.
Who initiates a single case agreement?
It often works best when the client contacts their plan first, since the plan's obligation is to its member. The therapist usually handles the clinical details and negotiation.
How long does it take to get a single case agreement?
It varies by plan. Some move quickly, and others take weeks, especially if they ask for more documentation. Start early and keep notes on every call, including the date of the call, the representative you spoke with, outcome of the call, and any reference number given.
How long does a single case agreement last?
As long as the agreement says. Most SCAs cover a set date range, a set number of sessions, or both. Request an extension before it expires if the client needs more care.
Is a single case agreement the same as an authorization?
No. An SCA sets your network status and rate for one client. A prior authorization is the plan's decision that a service is medically necessary. You may need both.
Can you get a single case agreement with Medicaid?
It depends on your state and the client's Medicaid plan. Contact the plan or your state Medicaid agency to ask about options for out-of-network providers.
Is there a single case agreement template?
Most plans have their own SCA forms, so ask the payor first.
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