{"id":6719,"date":"2026-07-07T12:56:08","date_gmt":"2026-07-07T12:56:08","guid":{"rendered":"https:\/\/medibillmd.com\/blog\/?p=6719"},"modified":"2026-07-07T12:56:09","modified_gmt":"2026-07-07T12:56:09","slug":"single-case-agreement","status":"publish","type":"post","link":"https:\/\/medibillmd.com\/blog\/single-case-agreement\/","title":{"rendered":"What is a Single Case Agreement (SCA) in Healthcare?"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Do you know that a single case agreement, or SCA for short, enables a patient to continue treatment with an out-of-network clinician without the need to pay extra charges?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">But what exactly is it? It is a customized, one-time contract between an out-of-network healthcare provider and an insurance payer. It enables a patient to receive care from an uncovered provider while retaining their in-network benefits. While it helps the provider secure in-network rates from the payer, it also prevents denials because of being an out-of-network provider.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This guide covers everything you need to know about these one-time contracts, from their importance to key requirements. So, continue reading!<\/p>\n\n\n\t\t\t\t<div class=\"wp-block-uagb-table-of-contents uagb-toc__align-left uagb-toc__columns-1 uagb-toc__collapse uagb-block-9bb10573      \"\n\t\t\t\t\tdata-scroll= \"1\"\n\t\t\t\t\tdata-offset= \"30\"\n\t\t\t\t\tstyle=\"\"\n\t\t\t\t>\n\t\t\t\t<div class=\"uagb-toc__wrap\">\n\t\t\t\t\t\t<div class=\"uagb-toc__title\">\n\t\t\t\t\t\t\tTable Of Contents\t\t\t\t\t\t\t\t\t\t\t\t\t<svg xmlns=\"https:\/\/www.w3.org\/2000\/svg\" viewBox= \"0 0 384 512\"><path d=\"M192 384c-8.188 0-16.38-3.125-22.62-9.375l-160-160c-12.5-12.5-12.5-32.75 0-45.25s32.75-12.5 45.25 0L192 306.8l137.4-137.4c12.5-12.5 32.75-12.5 45.25 0s12.5 32.75 0 45.25l-160 160C208.4 380.9 200.2 384 192 384z\"><\/path><\/svg>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uagb-toc__list-wrap \">\n\t\t\t\t\t\t<ol class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#significance-of-sca-for-healthcare-providers\" class=\"uagb-toc-link__trigger\">Significance of SCA for Healthcare Providers<\/a><ul class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#secures-in-network-reimbursement-rates\" class=\"uagb-toc-link__trigger\">Secures In-Network Reimbursement Rates<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#minimizes-financial-burden-on-patients\" class=\"uagb-toc-link__trigger\">Minimizes Financial Burden on Patients<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#expands-patient-access-retention\" class=\"uagb-toc-link__trigger\">Expands Patient Access &amp; Retention<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#guarantees-continuity-of-care\" class=\"uagb-toc-link__trigger\">Guarantees Continuity of Care<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#safeguards-practice-revenue\" class=\"uagb-toc-link__trigger\">Safeguards Practice Revenue<\/a><\/li><\/ul><\/li><li class=\"uagb-toc__list\"><a href=\"#requirements-for-a-single-case-agreement\" class=\"uagb-toc-link__trigger\">Requirements for a Single Case Agreement<\/a><li class=\"uagb-toc__list\"><a href=\"#single-case-agreements-with-payers\" class=\"uagb-toc-link__trigger\">Single Case Agreements with Payers<\/a><ul class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#medicare\" class=\"uagb-toc-link__trigger\">Medicare<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#medicare-advantage\" class=\"uagb-toc-link__trigger\">Medicare Advantage<\/a><li class=\"uagb-toc__list\"><li class=\"uagb-toc__list\"><a href=\"#medicaid\" class=\"uagb-toc-link__trigger\">Medicaid<\/a><\/li><\/ul><\/li><\/ul><\/li><li class=\"uagb-toc__list\"><a href=\"#single-case-agreement-vs-gap-exception\" class=\"uagb-toc-link__trigger\">Single Case Agreement vs. Gap Exception<\/a><li class=\"uagb-toc__list\"><a href=\"#streamline-your-billing-operations-with-medibillmd\" class=\"uagb-toc-link__trigger\">Streamline Your Billing Operations with MediBillMD<\/a><\/ul><\/ul><\/ol>\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Significance of SCA for Healthcare Providers<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Let\u2019s review how the SCA contract helps healthcare providers:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Secures In-Network Reimbursement Rates<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">What happens when an SCA insurance contract is in place? Even if you are an out-of-network provider, you can still ensure that you receive a fair and negotiated rate directly from the payer. This rate typically matches the standard in-network reimbursement levels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The benefit? This protects you from arbitrary out-of-network payouts or complete reimbursement rejections.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Minimizes Financial Burden on Patients<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Single case agreement in insurance billing ensures that the payer treats the care as in-network. This means the patient only owes the practice their standard co-insurance, co-pay, or deductible.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">How does it benefit the provider? It prevents the practice from having to balance-bill patients for out-of-pocket costs. The outcome? Reduced unpaid bills and improved patient relationships.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Expands Patient Access &amp; Retention<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Do you know that with a single case agreement, you can treat more patients with complex and rare conditions who otherwise could not afford out-of-network care?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The result? Your practice enjoys a broader patient base without forcing individuals to seek alternative, in-network competitors.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Guarantees Continuity of Care<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Is your practice treating critical or long-term conditions, such as behavioral health or specialized medical therapies? With an SCA contract, you can guarantee care continuity.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">How? It enables treatment to continue seamlessly without forcing the patient to find a new in-network clinician.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Safeguards Practice Revenue<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">An SCA in insurance billing establishes legally binding payment terms, explicit billing codes, and pre-authorization before you deliver the care. This prevents administrative confusion, lowers the risk of post-care claim denials, and ensures a smoother billing cycle.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Requirements for a <\/strong><strong>Single Case Agreement<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Typically, payers qualify healthcare practitioners for an SCA contract only if the following requirements are met:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>There is an absence of qualified in-network providers in the patient&#8217;s geographical area who can treat the specific condition.<\/li>\n\n\n\n<li>The out-of-network clinician possesses a specialized skill set, treatment method, or clinical expertise necessary for the patient&#8217;s care that existing in-network healthcare providers lack.<\/li>\n\n\n\n<li>In case a patient is transitioning to a payer or a clinician is leaving a network mid-treatment. Besides, switching providers would be harmful or disruptive to the patient\u2019s health mid-treatment. Note that this situation is more common in behavioral health or complex medical treatments.<\/li>\n\n\n\n<li>Out-of-network providers must submit detailed clinical documentation to establish medical necessity and secure prior authorization before the payer negotiates the single case agreement.<\/li>\n\n\n\n<li>The payer and the clinician must agree on a set reimbursement rate, the exact procedural code to bill, and the specific number of allowed sessions or timeframe.<\/li>\n\n\n\n<li>The out-of-network provider must fulfill the insurance payer\u2019s standard requirements. That is, you must maintain active state licensure, specific professional credentials, malpractice insurance, or any other requirements set by the payer.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Single Case Agreements<\/strong><strong> with Payers<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Discussed below are some insights about how different payers see SCA contracts:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Medicare<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">If you have been tired of looking for how you can secure an SCA with traditional Medicare, stop now! But why? Because it neither offers nor utilizes a single case agreement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The reason? Traditional Medicare does not operate via restricted provider networks. Simply put, Medicare beneficiaries can seek care from any healthcare practitioner nationwide who accepts Medicare. As a result, an out-of-network contractual exception is unnecessary.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For context, a healthcare provider&#8217;s relationship with Medicare is strictly binary. That is, you can have either of the following statuses:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Participating (PAR): <\/strong>A provider who is enrolled with Medicare and accepts the program&#8217;s approved amount as full payment for all covered services.<\/li>\n\n\n\n<li><strong>Non-Participating (Non-PAR): <\/strong>These providers are also enrolled with Medicare. However, Non-PAR providers may choose per claim whether to accept assignment.<\/li>\n\n\n\n<li><strong>Opted Out: <\/strong>Any healthcare provider who opts out of Medicare is completely outside the Medicare program for at least two years.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Medicare Advantage<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Medicare Advantage plans may agree to SCA contracts. Note that private insurance companies, such as Aetna, United Healthcare, and Blue Cross Blue Shield, manage Medicare Advantage. Besides, they have a limited network of providers. As a result, they can and do sign SCA contracts with providers.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">However, there is a catch! Private payers frequently refer to an SCA as a network gap exception because it is issued due to network deficiencies.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Also, getting an SCA under a Medicare Advantage plan is generally more challenging than it is with private insurance carriers. The reason? Medicare strictly audits whether a true gap in network coverage exists before agreeing to an out-of-network exception.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Medicaid<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Single case agreements are very common in Medicaid plans. The reason? There are often no in-network options, and out-of-network benefits are unavailable.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">So, how can you get an SCA contract?<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Justify<\/strong> that the specific case meets the criteria:\u00a0<\/li>\n<\/ol>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Continuity of care (mid-treatment insurance changes)<\/li>\n\n\n\n<li>Specialization (rare clinical expertise)<\/li>\n\n\n\n<li>\u00a0Network inadequacy (no local in-network options)<\/li>\n<\/ul>\n\n\n\n<ol start=\"2\" class=\"wp-block-list\">\n<li><strong>Document<\/strong> the diagnostic codes, targeted procedural codes, and clinical proof explaining why an in-network clinician cannot provide this care.<\/li>\n\n\n\n<li><strong>Submit<\/strong> the packet to the payer&#8217;s authorization department through an online portal or fax, and have the patient request an internal case manager to expedite the process.<\/li>\n\n\n\n<li><strong>Negotiate<\/strong> the reimbursement rate.<\/li>\n\n\n\n<li><strong>Obtain<\/strong> a formal, written contract with complete details before starting treatment to prevent claim denials. These include approved procedural codes, exact payout rates, and authorization dates.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Single Case Agreement<\/strong><strong> vs. Gap Exception<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The table below offers an at-a-glance view of the key differences between a single case agreement and a gap exception:<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><thead><tr><th class=\"has-text-align-center\" data-align=\"center\"><\/th><th class=\"has-text-align-center\" data-align=\"center\"><strong>Gap Exception<\/strong><\/th><th class=\"has-text-align-center\" data-align=\"center\"><strong>SCA<\/strong><\/th><\/tr><\/thead><tbody><tr><td class=\"has-text-align-center\" data-align=\"center\"><strong>What does it entail?<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">It is an internal insurance policy approval that temporarily treats an out-of-network provider as in-network.<\/td><td class=\"has-text-align-center\" data-align=\"center\">It is a specific, negotiated one-time legal contract between a payer and an out-of-network provider for a single patient.<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\"><strong>When does it become applicable?<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">When the insurance plan lacks any local or qualified in-network specialists to fill a gap (network deficiencies).<\/td><td class=\"has-text-align-center\" data-align=\"center\">It focuses on provider-centric qualifications. That is, when continuity of care with a trusted clinician or highly specialized treatment methods is needed.<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\"><strong>Who negotiates it?<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">Requested primarily by the patient or case manager via member services. However, the payer decides standard in-network pricing.<\/td><td class=\"has-text-align-center\" data-align=\"center\">The payer and provider mutually decide on agreeable rates.<\/td><\/tr><tr><td class=\"has-text-align-center\" data-align=\"center\"><strong>How long does it stay active?<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">The agreement stays active for a strict, temporary window until the payer can contract an in-network provider to fill the gap.<\/td><td class=\"has-text-align-center\" data-align=\"center\">The duration is primarily tied directly to the length or course of the specific treatment plan.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Streamline Your Billing Operations with MediBillMD<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">To summarize, single case agreements are an integral tool that enables you to accept and treat patients while being an out-of-network provider. However, you must fulfill the specific payer requirements to secure one.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">In case you are experiencing a high denial rate or unsteady cash flow, it is time you consider onboarding professionals to help you with your billing cycle. At MediBillMD, we have a team of certified professional coders and billing specialists. We audit the practice\u2019s billing operations, identify root causes, tailor a specialty-specific solution, and achieve quantifiable results.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Thus, if you want to experience all that and more, feel free to opt for MediBillMD\u2019s <a href=\"https:\/\/medibillmd.com\/services\/medical-billing-services\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>medical billing services<\/strong><\/a>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Do you know that a single case agreement, or SCA for short, enables a patient to continue treatment with an [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":6720,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","content-type":"","_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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