SCAs: one patient, one negotiated rate
Summary
A single case agreement (SCA) is a one-patient contract between a payer and an out-of-network provider, usually struck when the plan has no in-network clinician who can meet that member's need. Your leverage is network adequacy and continuity of care, not goodwill. Ask before the first session, get the rate, the authorized codes, the visit count, the date range, and the timely-filing window in writing, and confirm the single claim address.
By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.
What a single case agreement is
A single case agreement (SCA) is a contract between a health plan and an out-of-network provider that covers one named patient, usually for a defined set of services over a defined period. It exists because the member needs care the plan cannot supply in-network, so the plan agrees — for this one case — to treat you as if you participated, at a rate the two of you negotiate.
An SCA is not a network contract and does not credential you for anyone else. Without one, the patient is out-of-network and billed under the plan's out-of-network or self-pay rules, and the money conversation shifts onto the patient. The SCA is the tool that converts a single out-of-network relationship into a paid, in-network-priced one — for that patient, those codes, and that window only. It sits between full participation and pure out-of-network billing.
When you actually have leverage
Your leverage for an SCA is structural, not personal: it is strongest when the plan cannot meet its own network adequacy obligation for this member. The usual triggers are a specialty or language the in-network panel lacks, a geographic gap, a wait time that delays needed care, and continuity of care when a member's provider leaves the network mid-treatment. These are the same facts that support a gap exception, so build the request on them rather than on fairness.
The request path and the criteria belong to each payer and live in its own published materials — Aetna 1Ref 1Aetna (2026).Aetna Clinical Policy Bulletins.Named example that a national commercial payer publishes its provider policies online, where its out-of-network authorization and gap-exception process is documented., UnitedHealthcare 2Ref 2UnitedHealthcare (2026).UnitedHealthcare Policies and Protocols.Named example that UnitedHealthcare publishes its provider policies and protocols online, so an SCA or gap-exception request follows that payer's own published process., and Cigna 3Ref 3Cigna (2026).Cigna Coverage and Claims Policies.Named example that Cigna publishes its coverage and claims policies online, the payer-owned materials that govern how it handles an out-of-network authorization. each publish their provider policies online, and the version in force when you ask is the one that governs. Document the network deficiency concretely: which in-network providers you or the member contacted, their availability, and why they could not serve. A gap exception grounded in network adequacy is far harder to refuse than an appeal to goodwill.
What to nail down in the written SCA
An SCA is only as good as its written terms, and a verbal "yes" from a rep is not an SCA. Before you see the patient, get a written agreement or an authorization document carrying these terms, because everything left unstated defaults to the payer's advantage at claim time. The items below are what a solo provider should confirm in writing.
| Term | What to pin down | Why it bites later |
|---|---|---|
| Rate | The exact allowed amount per code | "Usual and customary" is not a number |
| Authorized codes | The specific CPT codes covered | An unlisted code denies |
| Visit count | Number of sessions authorized | Care past the count is unpaid |
| Date range | Effective and end dates | Sessions outside the window deny |
| Timely filing | The days you have to file | Out-of-network windows can be short |
| Claim submission | The exact payer ID and claim address | An SCA often routes to a different address |
| Authorization number | The reference to put on the claim | Claims without it reject |
Keep the signed SCA or authorization letter with your contract file. When the claim underpays or denies, that document is the appeal — it is the only proof that the plan agreed to these terms for this patient.
The No Surprises Act backdrop when there is no SCA
If the plan declines the SCA and the patient still chooses to see you out-of-network, the No Surprises Act frames the money conversation. For uninsured and self-pay patients you must provide a good-faith estimate of expected charges, and the Act restricts balance billing in defined settings and creates a patient-provider dispute-resolution process for contested estimates 4Ref 4Centers for Medicare & Medicaid Services (2026).No Surprise Billing.That the No Surprises Act requires a good-faith estimate for uninsured and self-pay patients, restricts balance billing in defined settings, and creates a patient-provider dispute-resolution process — the rules that apply when a patient is billed out-of-network without an SCA..
Treat the estimate as a compliance document, not a marketing quote: give it before service, keep a copy, and state your cash rate and cancellation terms plainly. Collecting the patient's payment at the visit and issuing a superbill for their own out-of-network reimbursement is a legitimate path when no SCA is available. Patient billing that is clear up front is what avoids the surprise the Act exists to prevent, and it keeps the cash relationship defensible if the estimate is later questioned.
Do Medicare and Medicaid do SCAs?
Government payers rarely do commercial-style single case agreements. Medicaid is the largest payer for behavioral health in the country and is administered state by state, so its coverage and its out-of-network authorization design vary by state 5Ref 5Centers for Medicare & Medicaid Services (2026).Behavioral Health Services.That Medicaid is the largest U.S. payer for behavioral health and is state-administered, so its coverage and out-of-network authorization design vary by state rather than following a national rule.; what one state Medicaid program allows for an out-of-network provider, a neighboring one may not. Check your state's Medicaid agency rules before assuming an SCA-like path exists.
Medicare generally expects you to enroll and bill under its own rules rather than negotiate one-off rates, so the SCA question is mostly a commercial-plan and Medicaid-managed-care question. When a Medicaid managed care plan lacks an adequate network for a member, a state may require an out-of-network arrangement — but that requirement, and the rate, come from the state program, not from a national standard you can quote back to the plan.
How to make the ask
Make the ask early and in a specific order. First confirm the patient's out-of-network benefits and whether the plan uses a behavioral-health carve-out, because the request may go to the carve-out vendor rather than the plan itself. Then call the number on the member's card, ask for the single case agreement or gap exception process by name, and get a reference number for the request the moment it is opened.
Put the clinical and network-adequacy justification in writing, propose your rate with a short rationale, and ask for the agreement or authorization letter before the first session — care delivered before the SCA is signed is care you may not be paid for. If you work SCAs in behavioral health regularly, keep a one-page template of your standard terms so each request starts from the same place. Understanding how credentialing, enrollment, and contracting differ helps you frame the SCA as the narrow, one-patient instrument it is.
Common questions
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- 1.Aetna (2026). Aetna Clinical Policy Bulletins. Aetna provider portal. link ✓Named example that a national commercial payer publishes its provider policies online, where its out-of-network authorization and gap-exception process is documented.
- 2.UnitedHealthcare (2026). UnitedHealthcare Policies and Protocols. UnitedHealthcare provider portal. link ✓Named example that UnitedHealthcare publishes its provider policies and protocols online, so an SCA or gap-exception request follows that payer's own published process.
- 3.Cigna (2026). Cigna Coverage and Claims Policies. Cigna provider portal. link ✓Named example that Cigna publishes its coverage and claims policies online, the payer-owned materials that govern how it handles an out-of-network authorization.
- 4.Centers for Medicare & Medicaid Services (2026). No Surprise Billing. Centers for Medicare & Medicaid Services (CMS). link ✓That the No Surprises Act requires a good-faith estimate for uninsured and self-pay patients, restricts balance billing in defined settings, and creates a patient-provider dispute-resolution process — the rules that apply when a patient is billed out-of-network without an SCA.
- 5.Centers for Medicare & Medicaid Services (2026). Behavioral Health Services. Medicaid.gov. linkThat Medicaid is the largest U.S. payer for behavioral health and is state-administered, so its coverage and out-of-network authorization design vary by state rather than following a national rule.
https://www.gale.care/for-providers/ct-single-case-agreements · 5 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.