Not every patient who needs care will have an insurance plan that fits neatly into your existing contracts. A prospective client may have out-of-network benefits, a payer you do not usually work with, or a clinical situation where your facility is the right fit even though there is no formal agreement already in place.

That’s where a single case agreement can come into the conversation. In behavioral health billing, single case agreements can create a pathway to serve a specific patient under negotiated terms with the payer. They’re not always simple, and they’re not guaranteed, but when handled correctly, they can help connect patients to appropriate care while giving providers a clearer reimbursement framework.

Let’s explain what a single case agreement is, when it may be used, and what behavioral health providers should understand before entering into one.

What Is a Single Case Agreement?

A single case agreement, commonly called an SCA, is a temporary, patient-specific contract between an out-of-network provider and an insurance payer. Under an SCA, the payer agrees to cover care for one specific patient under a defined set of terms.

For behavioral health providers that operate out of network with certain payers, SCAs can be a practical tool for securing coverage at a predictable rate. Instead of leaving reimbursement to standard out-of-network processing, an SCA gives both the provider and payer a clearer framework for authorization, billing, and payment.

When Would a Provider Need an SCA?

SCAs don’t come up randomly. There are specific circumstances where pursuing one makes clinical and financial sense for a provider or treatment center.

• The patient has coverage, but your facility is out-of-network with their plan. This is the most straightforward reason. The patient has active insurance, the payer covers behavioral health services, but there’s no contract in place between your facility and that specific plan. An SCA creates a defined reimbursement agreement for that patient’s care.
• There are no appropriate in-network providers available. If a patient’s plan cannot produce an in-network provider who can meet their clinical needs, that’s a strong basis for an SCA request.
• Your facility offers a specialized service the payer’s network doesn’t cover. A payer’s network may technically include behavioral health providers, but if those providers don’t offer the treatment the patient needs, the network may not be clinically adequate for that case.
• The patient has an established clinical relationship with your provider or program. When a patient has an established therapeutic relationship, is mid-treatment, or has a history that makes transferring to a new provider clinically risky, payers are often more receptive to an SCA.
• The patient requires a specific level of care or treatment setting that isn’t available in-network. Residential treatment, partial hospitalization, and intensive outpatient programs are frequently underrepresented compared to standard outpatient therapy. If a patient requires a level of care that the payer’s network can’t provide, that’s an opening for an SCA conversation.
• The payer is open to approving the case without creating a full network contract. Some payers use SCAs because they don’t want to add a provider to their network but still need to address a legitimate access gap for a specific member.

How the Single Case Agreement Process Works

Here’s how the SCA process typically flows from the provider side.

Step 1: Confirm the patient’s benefits and out-of-network status.

Before anything else, verify the patient’s coverage thoroughly. You need to know whether the plan includes any out-of-network benefits, what the patient’s out-of-network deductible and cost-sharing look like, and whether behavioral health services require prior authorization.

Step 2: Identify why an SCA is appropriate for this case.

An SCA request is stronger when it’s built on a specific reason, not just the fact that you’re out-of-network. Before you contact the payer, be clear on your clinical and operational basis. The clearer your rationale going in, the more leverage you have in the conversation.

Step 3: Gather your documentation.

A well-supported SCA request typically includes the patient’s diagnosis, clinical history relevant to the referral, a medical necessity statement, the proposed treatment plan, and the level-of-care determination. Payers are more likely to approve these requests.

Step 4: Submit the SCA request to the right department.

Contact the payer’s provider relations or network management department. Identify yourself as a provider requesting a single case agreement for a specific patient and be prepared to walk through your clinical rationale.

Step 5: Negotiate the terms.

Once the payer is open to an SCA, the actual terms are often negotiable. The agreement should specify the reimbursement rate, the exact services covered, the dates of service or length of stay authorized, how concurrent reviews will be handled, and what the billing requirements are.

Step 6: Get the agreement in writing before billing.

A verbal confirmation that an SCA will be approved is not an SCA. Do not begin billing until you have the agreement documented in writing with the agreed terms clearly stated. The written SCA is your basis for every claim you submit.

Step 7: Track claims against the agreed terms.

Billing under an SCA isn’t set-and-forget. Claims need to be submitted with the correct procedure codes, modifiers, and billing notes that align with what the SCA specifies. Payment should be tracked against the negotiated rate, not just accepted at face value.

What Should Be Included in a Single Case Agreement?

Once a payer agrees to an SCA, providers and billing teams often focus on getting services started. However, an SCA is only as useful as what’s actually written in it. Before a single claim goes out the door, every item below should be confirmed, documented, and accessible to whoever is handling billing for that account.

• Patient name and member ID
• Provider or facility name and NPI
• Covered dates of service
• Approved level of care or service type
• Billing codes
• Authorization requirements
• Reimbursement rate
• Claim submission instructions
• Timely filing deadline
• Appeal rights
• Payment timeline
• Scope of the agreement

Single Case Agreements and Reimbursement: What Providers Should Know

Getting an SCA approved is not the finish line but the beginning of the billing process. Verbal confirmations from payer representatives are not binding, and vague rate language like “usual and customary” gives payers room to define reimbursement on their own terms. Before billing begins, the agreement needs to be in writing and the reimbursement rate needs to be specific.

Authorization and SCA approval are also not the same thing. An SCA establishes the contractual terms for the case; authorization establishes clinical approval for the specific services rendered. If a separate prior auth is required, it still needs to happen before claims go out.

Once claims are submitted, monitoring doesn’t stop. Payer claims systems don’t automatically update to reflect negotiated SCA rates, which means underpayments can come through. Catching them requires actively comparing each payment against the agreed rate. Managing SCAs well from approval through final payment requires billing expertise that goes beyond standard claims processing, which is exactly what Integrity Billing provides.

Single Case Agreement vs. In-Network Contract

A single case agreement and a standard in-network contract both establish a relationship between a provider and a payer, but they serve very different purposes. An in-network contract is ongoing, covers all eligible patients across every episode of care, and processes claims automatically once credentialing is complete. An SCA is the opposite. It’s temporary by design, patient-specific by definition, and limited to the services, dates, and level of care approved for one case.

That distinction has direct implications for billing and revenue planning. Claims under an SCA need to be managed as individual cases with their own rate confirmations, authorization tracking, and remittance monitoring.

How a Billing Team Can Help With Single Case Agreements

Managing an SCA well requires expertise at every stage of the process. An experienced billing team knows how to identify SCA opportunities during benefits verification, build a compelling case for approval, and negotiate specific terms. Once an agreement is in place, that same team tracks authorization deadlines, monitors concurrent review dates, manages any amendments when treatment extends or level of care changes, and submits claims correctly the first time.

The work doesn’t stop at submission. Remittances need to be reviewed against the agreed rate on every claim because underpayments under SCAs are common. For behavioral health providers, treatment centers, and ABA practices navigating out-of-network reimbursement, that level of active management across every case means fewer write-offs, fewer preventable denials, and more predictable revenue.

Partner With Integrity Billing for SCA Management

Single case agreements are one of the more complex and high-stakes areas of behavioral health billing. When they’re managed well, they protect reimbursement, reduce denials, and make out-of-network care financially viable for providers. When they’re not, the cost shows up in underpayments, write-offs, and revenue that was earned but never collected. Integrity Billing specializes in exactly this kind of work.

If your practice is managing out-of-network cases and you’re not confident that your SCA process is as tight as it needs to be, we’d love to connect. Contact Integrity Billing today at 888-368-7461 to learn how we can support your revenue cycle and make sure the agreements you work hard to secure are actually paying what they should.

Frequently Asked Questions About SCAs

What does single case agreement mean?

An SCA is a one-time or case-specific agreement between an insurance company and an out-of-network provider for a specific patient’s care.

Is a single case agreement the same as an authorization?

No. An authorization may approve medical necessity for a service, while an SCA should also clarify whether the payer agrees to cover that provider and under what reimbursement terms.

How long does a single case agreement last?

It depends on the agreement. Some cover a specific date of service, while others cover a defined treatment episode, admission, or authorization period.

Can a single case agreement be used with Medicaid or Medicare?

Sometimes, but rules vary by payer, plan type, and state. Providers should confirm the payer’s requirements before assuming an SCA is available.

Who requests a single case agreement?

The request may involve the provider, payer, patient, family, case manager, or billing team, depending on the payer’s process.

Can a single case agreement be denied?

Yes. A payer may deny the request if it believes in-network care is available, medical necessity is not established, or the request does not meet plan rules.

What should providers confirm before billing under a single case agreement?

Providers should confirm the covered services, dates, reimbursement rate, authorization requirements, claim submission rules, and whether the agreement is documented in writing.