When a client needs your program but you're not in their network, a single case agreement can make the insurer pay anyway. Here's how SCAs work and how to actually get one.
A single case agreement (SCA) is a one-time contract between an insurance company and an out-of-network provider that covers one specific patient, usually for a defined service and time period, at a negotiated rate. Insurers grant SCAs when their network can't meet the patient's needs — no in-network provider offers the required specialty or level of care within a reasonable distance, or the patient needs continuity of care with an existing provider. The patient typically pays in-network cost sharing even though the provider is out-of-network.
Confirm the plan, then document why no in-network option works: searches of the payer's directory, distances, waitlists, and the clinical need.
The request rises or falls on clinical documentation — diagnosis, ASAM level justification, and why this provider specifically. This mirrors utilization review standards.
Propose a case rate or per-diem anchored to your usual rates. Get the covered services, authorized units, effective dates, and billing instructions in writing before treating.
SCAs are unforgiving — claims that don't match the agreed codes, dates, or units get denied. Track authorization expirations and request extensions early.
SCAs are patient-by-patient and labor-intensive — useful for occasional out-of-network admissions, a bridge while your credentialing is pending, or genuinely niche services. If you're requesting SCAs from the same payer repeatedly, that's the signal to pursue a full network contract: predictable rates, less per-case negotiation, and referral flow from the payer's directory.
A single case agreement (SCA) is a one-time contract between an insurer and an out-of-network provider covering one specific patient, usually for defined services, dates, and a negotiated rate. The patient typically pays in-network cost sharing even though the provider is out-of-network.
Most commonly when the network can't meet the patient's needs — no in-network provider offers the required specialty or level of care within a reasonable distance or timeframe (a network gap), or when continuity of care with an existing provider is clinically necessary.
Verify the patient's benefits, document the network gap (directory searches, distances, waitlists), submit a medical-necessity case with diagnosis and level-of-care justification, then negotiate the rate, covered services, and authorized units in writing before treating.
An SCA covers one patient, one episode; a network contract covers all of the payer's members on standing terms. Programs that repeatedly win SCAs from the same payer usually benefit from pursuing full credentialing and contracting instead.
How to get in-network and reimbursed.
How payers decide what care they'll cover.
The receipt clients use for out-of-network reimbursement.
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