SCAs in BH: continuity as the argument

What a single case agreement is

A single case agreement is a contract between an out-of-network clinician and a health plan covering one patient, at a rate the two of you negotiate, so the plan pays for care it would otherwise treat as out-of-network. It is narrower than joining the network — it covers this patient only — and different from a gap exception, which pays your out-of-network claim at the in-network benefit level without setting a new rate. The SCA sets the price; the gap exception adjusts the benefit.

That makes it a tool for a specific situation, not a substitute for network participation. Joining a panel is a separate path — credentialing, enrollment, and contracting — and being reached through rental networks or an IPA's route into networks is yet another. A single case agreement is what you use when none of those apply but this one patient still needs the plan to pay for you.

Continuity of care: the strongest argument

For a client already in treatment with you, continuity of care is the argument that carries the most weight, because it is the one the plan has the hardest time refusing. Interrupting an established therapeutic relationship to move a patient to a stranger mid-course is disruptive and clinically costly, and plans understand that transferring an actively treated patient rarely goes well. Frame the request around the patient's existing progress and the risk of restarting, not around your preference to keep the client.

This argument is strongest at a transition — a client whose employer changed plans, or whose coverage shifted to a carve-out that does not include you. The care predates the coverage change, the relationship is working, and moving the patient now would set treatment back. That is a concrete continuity claim, not a general appeal, and concrete claims are the ones a case manager can approve.

The network-adequacy argument

The continuity argument gets stronger when you pair it with the network-adequacy gap. If the plan cannot point to an in-network therapist who has your specialty, takes new patients, and is reachable within a reasonable distance and wait, then it has no adequate alternative to offer — and network admission is a limitation parity law expects the plan to apply no more stringently to behavioral health than to medical care 1Ref 1U.S. Department of Labor (2026).Mental Health and Substance Use Disorder Parity.That network admission is a non-quantitative treatment limitation MHPAEA expects a plan to apply no more stringently to behavioral health — the adequacy-gap basis for a single case agreement.. Two arguments together — an established relationship and no real in-network option — are harder to deny than either alone.

Do the legwork that makes the gap real. Before or during the request, call down the plan's own directory for the specialty the patient needs and note who has closed panels, who never responds, and how far the nearest available clinician is. That list is the evidence behind the adequacy claim, and it converts 'there is no one else' from an assertion into a record.

How to make the request

Make the request to the plan's case-management or behavioral-health authorization team, then confirm it in writing. Ask for a single case agreement by name, state the continuity and adequacy arguments, and propose a specific rate rather than waiting to be offered one. For a plan whose behavioral health runs through a portal like Optum's Provider Express, the authorization and case-agreement request routes through that portal 2Ref 2Optum Behavioral Health (2026).Provider Express.Optum's Provider Express as the authorization and network portal for a large behavioral-health carrier — a named example of where an out-of-network authorization or case-agreement request routes, not a claim about all payers.. Read the plan's own reimbursement policy first — Anthem, for instance, posts its reimbursement policies on its provider portal 3Ref 3Anthem (2026).Anthem Provider Policies.Anthem publishing its reimbursement policies on its provider portal, cited only as that payer's own published example with 'your contract controls' framing. — because each plan's process differs and your contract controls.

Have the codes ready so the agreement covers what you actually bill: 90791 for an evaluation, 90834 or 90837 for individual sessions, 90847 for family work 4Ref 4APA Services, Inc. (2025).Psychotherapy Codes for Psychologists.The psychotherapy CPT family — 90791 evaluation, 90834/90837 individual therapy, 90847 family — the single case agreement needs to cover.. Propose a rate you can justify from your usual fee and the market, and ask the case manager what documentation they need — usually a brief clinical rationale for continuity and the adequacy findings you gathered.

Get it in writing

An SCA is only as good as what it specifies, so do not start the next authorized period until the terms are documented. The written agreement should name the authorization or reference number, the exact CPT codes it covers, the negotiated rate for each, the number of sessions approved, and the date range it spans. Confirm how to bill against it and where to send claims, because an SCA that is not billed the way the plan expects is denied like any other claim.

The terms worth pinning down:

• The authorization number and the plan contact who issued it.
• The covered codes and the rate for each.
• The session count and date range the agreement authorizes.
• The billing instructions — claim format, any required modifier, where claims go.

Calendar the expiration. Request re-authorization before the approved sessions or the date range run out, with a short update on the patient's progress, so coverage does not lapse between agreements.

If the plan says no

If the plan refuses, you still have moves. Appeal the denial through the plan's process, adding any adequacy evidence you gathered — the in-network clinicians you called who were unavailable. If a behavioral-health carve-out is the one refusing, being dropped by the carve-out or denied a rate is itself something you can escalate to the plan behind it. And if no agreement materializes, the client can continue with you on a self-pay basis.

That fallback has its own paperwork. Give a good-faith estimate as the No Surprises Act requires for a self-pay client, and provide the oon superbill so they can pursue out-of-network reimbursement themselves 5Ref 5Centers for Medicare & Medicaid Services (2026).No Surprise Billing.That the No Surprises Act requires a good-faith estimate for a self-pay client — the fallback when no single case agreement is reached. As of July 2026.. It is not the outcome you wanted, but it keeps the treatment intact while you appeal — and an appeal backed by a documented adequacy gap and a continuity rationale sometimes turns a first no into a later yes.