Single Case Agreement

A one-time contract between an out-of-network provider and a payer to provide specific services to a specific patient at an agreed-upon rate.

A single case agreement is a one-off deal between you and a payer for a specific patient when you are not in their network. The payer agrees to reimburse you at a negotiated rate for that particular patient's care, without requiring you to go through the full credentialing and enrollment process. SCAs are most common when a patient needs specialized care that is not available from an in-network provider. For example, if a health plan member needs a rare surgical procedure and the only qualified surgeon in the region is out-of-network, the payer may agree to an SCA rather than having the member travel hundreds of miles to an in-network provider. The process typically starts with the patient or their referring provider contacting the payer to request an SCA. The payer evaluates whether in-network alternatives are available. If not, they reach out to you to negotiate terms. You agree on the rate (usually somewhere between your full charge and the payer's in-network rate), the scope of services covered, and the duration of the agreement. SCAs are also common in behavioral health. Mental health provider networks are notoriously thin, and patients often cannot find an in-network therapist or psychiatrist accepting new patients. Many states have laws requiring payers to offer SCAs when their network cannot provide timely access to behavioral health services. From a credentialing perspective, SCAs bypass the full enrollment process. You do not become a network provider. The agreement covers only the specific patient and services described. Once the agreed-upon treatment is complete, the SCA ends and you are back to being out-of-network. If you are getting frequent SCA requests from the same payer, it is a sign that their network has gaps in your specialty. This gives you bargaining power to negotiate a full participation agreement with favorable terms, since they clearly need providers like you.