Single case agreements: how to get one, what to negotiate, how to bill it

What a single case agreement is

An SCA is a written agreement between a health plan and a provider that isn't in its network, covering one member's treatment: the services, the dates, the rate and how claims are paid. Plans also call it a letter of agreement, a single case contract or, on the member's side, a network gap exception or an out-of-network exception. It isn't a network contract, and it isn't an authorization. You still need the authorization, and the SCA ends when the episode does.

Option	What it means for the client	What it means for you
In-network contract	In-network cost share	Contract rate for every member, after credentialing (see getting insurance contracts)
Single case agreement	Usually in-network cost share, no balance bill beyond it	An agreed rate for this one client and episode
Out-of-network benefit	Higher deductible and coinsurance; may be balance billed	The plan's out-of-network allowance, often low, and collections from the client
Self-pay	Pays your self-pay rate, with a good faith estimate first	No plan involved

When plans grant them

A plan agrees to an SCA when it can't meet its member's need inside its own network. The common reasons:

• No in-network program at this level of care is reasonably close, or none can admit soon. PHP for substance use is the classic gap.
• The client needs something in-network programs don't offer: co-occurring care, medication for addiction treatment, a language, adolescent services, gender-specific or trauma-focused groups, or evening hours around work.
• Continuity of care: the client is already in your program when their plan changes, or is stepping down from your residential or PHP to your IOP.

The usual denial reason is "in-network options are available." Your file has to answer that, one option at a time. That's what the steps below are for.

How to ask: the 14 steps

1. Check benefits and the plan type. Run the benefits check, then call. Ask whether it's an HMO, EPO, PPO or POS plan, whether there's any out-of-network benefit for this level of care, and whether precertification is needed. Quick VOB's VOB checklist has the questions by level of care.
2. Find out who regulates the plan. A card marked TDI or DOI is fully insured, so Texas law applies. No mark, "administered by" or ASO means self-funded: federal law (ERISA) and the plan document apply, and the employer's HR team can push the administrator.
3. Ask the plan for every in-network program that can admit within 7 days near the client's ZIP code. Call the behavioral health line, not the medical one; if a carve-out company manages the benefit, it's their network (how carve-outs work). Get the rep's name and the reference number.
4. Search the plan's directory yourself and list every result, even the ones that obviously won't fit.
5. Call every option. Ask whether it runs this level of care for substance use, whether it's in network for this exact plan, its soonest admission, and whether it can meet this client's needs. Note the distance and the drive and bus time. Tag each one: can't take the client (and why), to confirm, or looks available. The plan will point to any option you left open, so resolve each before you send.
6. List the client's barriers: home ZIP code, transportation, work hours, and clinical needs such as co-occurring disorders, medication for addiction treatment, trauma, gender, language or a step-down from residential.
7. Write the clinical justification: diagnosis, the ASAM dimensions that support this level of care, and why a lower level won't hold. Our sister guide on prior authorization covers the ASAM dimensions reviewers ask about.
8. Ask the client to call the plan too. A member's own request for an exception carries weight. Give them a short script: their name and member ID, the level of care their clinician recommends, and that no in-network program can admit them in time.
9. Send the letter, signed by the clinical director or the owner. Record the date, where it went and the reference number.
10. Follow up every 2 business days, and log each call.
11. Escalate at 5 business days with no decision, or on any denial: ask for a supervisor and a peer-to-peer review, ask the plan to name in writing a program that can admit this client, and appeal. For a fully insured plan, the member can file a complaint with TDI. For a self-funded plan, use its appeal process and the employer's benefits team.
12. Get every term in writing (next section). A verbal yes isn't an agreement.
13. Put the authorization on file, with the next review date. The SCA sets the rate; the authorization approves the days.
14. Give billing the signed SCA and the authorization before the first claim.

Our working test of "reasonably available" is 30 miles, 60 minutes by bus or 45 by car, and an admission within 7 days. That's our own yardstick, not a legal standard. The letter quotes the facts, not our cutoffs.

The request letter

One to two pages, addressed to the plan's care management or network team, with:

• The member's name, date of birth and member ID (send it only to the plan, through its secure channel), and your NPI, tax ID, license and levels of care.
• What you're asking for: an SCA for named levels of care, with the codes, the expected dates and your proposed rate.
• The in-network options you contacted, each with the date, the distance and why it can't take this client now.
• The clinical justification and the client's barriers.
• For a state-regulated plan, a reference to the Texas network gap rules below.
• A request for a decision in writing, and who to call.

What to negotiate

Term	What to ask for
Rate	A daily rate for each level of care. Base it on your cost of care and your existing contract rates, not your billed charges: charges are not what plans pay. Know your floor before you call.
Levels and codes	Each level named with its codes, for example PHP as S0201 or revenue codes 0912/0913, and IOP as H0015 or revenue code 0906. Negotiate PHP and IOP separately, and include the step-down so the client doesn't need a new SCA mid-episode.
Units and dates	The whole episode, not just the first authorization: a start date, an end date or "through discharge," and the number of days at each level.
Authorization	The authorization number, the days approved, and the date of the next concurrent review.
Client cost share	In-network deductible, copay and coinsurance, and a statement that you won't balance bill beyond it.
Claims	The claim form (CMS-1500 or UB-04), the claims address or payer ID, any reference number to put on the claim, and the timely filing limit.
What's included	Whether psychiatric visits, assessments and drug tests are inside the daily rate or billed separately.

Getting it in writing

The SCA is real only when you have a document signed by the plan (and usually by you) that states the rate, the dates, the levels and codes, the units, the member's cost share and how to bill. Keep the plan's reference number, the rep's name and the date with it. Put a copy in the client's chart and in the billing file. If the plan sends terms by email instead of a signed agreement, reply confirming each term and ask for the signed version before the first claim.

Billing it

1. Bill exactly what the SCA lists: the codes, the claim form, the dates and the units, with the authorization number and any SCA reference the plan told you to include.
2. Bill only days inside the authorization. When an authorization ends, the SCA doesn't extend it: schedule the continued-stay review about 5 days before the last day.
3. Check every remittance against the SCA rate. A common mistake is the claim processing as out-of-network at the plan's allowance. Call with the SCA reference and ask for reprocessing; appeal in writing if needed.
4. Collect only the in-network cost share the SCA states.
5. Track the SCA's end date next to the authorization's, so neither lapses unnoticed.

Cima EHR's Program plan keeps every authorization's dates in the chart and prompts the continued-stay review before the last day, and Quick VOB runs the benefits check that starts step 1.

The Texas rules behind it

• State-regulated PPO and EPO plans: when covered services aren't available from a preferred provider in the service area, Texas Insurance Code §1301.005(b) requires payment at the in-network level, and TDI's rules (28 TAC §3.3707) require a documented network gap exception procedure, decided within five business days.
• State-regulated HMOs: Texas Insurance Code §1271.055 requires the HMO, at a network provider's request, to allow a referral to a non-network provider when services aren't available in network, pay it at the usual and customary or an agreed rate, and have a same-specialty reviewer look before denying. Ask the member's in-network doctor to send the request.
• Self-funded employer plans aren't regulated by TDI (TDI on self-funded plans). The plan document and federal ERISA claims rules apply; check with the U.S. Department of Labor.
• Fully insured plans' members can file a complaint with TDI when the plan won't follow its gap exception process.

Our guide to closed insurance networks covers Texas network adequacy rules in more depth.

Opening a program? The IOP / PHP Program Launch sets up your authorization and SCA workflow before the first admission. Or book a free 30-minute call.

Questions

What is a single case agreement in behavioral health?

A written agreement between a health plan and an out-of-network provider covering one member's treatment, at an agreed rate, usually with the member paying in-network cost sharing. Programs use them most for PHP and IOP when the plan's network has no program that can admit the client in time.

How long does it take to get a single case agreement?

It depends on the plan and how complete your request is. State-regulated Texas PPO and EPO plans must decide network gap exceptions within five business days under TDI's rules. Follow up every two business days and escalate at five with no decision.

Is a single case agreement the same as an authorization?

No. The SCA sets the rate and terms; the authorization approves the days or units. You need both before the first claim, and the authorization still needs continued-stay reviews.

Can we balance bill a client under a single case agreement?

Usually not. Most SCAs set in-network cost sharing and bar billing the client beyond it. Read your agreement and collect only what it states.

Why did the plan deny our single case agreement?

Most often because the plan says an in-network option is available. Answer it with each in-network program you contacted, the date, the distance and why it can't take this client now, then ask for a supervisor or a peer-to-peer and ask the plan to name in writing a program that can admit.

Can a single case agreement lead to a network contract?

It can help. Each SCA is the plan agreeing that its network couldn't serve that member. Count them and cite them in your request for a facility contract; see how to get insurance contracts.

Sources

• 28 Texas Administrative Code §3.3707 (network gap exceptions) and §3.3704 (availability of preferred providers); Texas Insurance Code §1301.005
• Texas Insurance Code §1271.055 (HMO out-of-network services); 28 TAC §11.1611
• Texas Department of Insurance, Self-funded plans and File a health insurance complaint
• CMS, No Surprises Act (good faith estimates for self-pay clients)