Single-case agreement

An SCA creates a narrow payment path

Health plans build networks through provider contracts. A single-case agreement can create a temporary, member-specific arrangement when ordinary network participation is unavailable or unsuitable under the payer's process.

Common triggers include a network gap, continuity need, specialized expertise, geographic shortage, or ongoing therapeutic relationship. The payer may use another label, such as a network-gap exception or single-patient agreement. Obtain the actual document instead of relying on the label.

The agreement and authorization answer different questions

The SCA defines contractual or payment terms between payer and provider. Prior authorization addresses the payer's coverage decision for specified services. A family may need both. A clinical recommendation remains the qualified clinician's judgment about care.

HealthCare.gov's preauthorization definition warns that authorization is no promise the plan will cover cost. An SCA can also leave payment conditions unresolved if the claim falls outside its service, provider, date, rate, or documentation terms.

Read every operative field

The agreement should identify:

• legal payer and provider parties
• member, product, group, and plan
• billing entity, rendering clinicians, supervisor, and locations
• covered service codes, modifiers, units, settings, and dates
• negotiated rate, fee schedule, or payment method
• clean-claim, timely-filing, attachment, and claim-routing rules
• prior-authorization requirement and reference
• member cost sharing and balance-billing restriction
• coordination-of-benefits and other-payer terms
• effective date, termination, renewal, dispute, and amendment process

Compare the executed copy with payer and provider systems before the first service and each claim release.

Network access rules can support the request

For Medicaid managed care, 42 CFR 438.206 requires an entity whose network cannot provide a necessary covered service to arrange timely out-of-network coverage for the enrollee. That duty does not itself create an SCA with the family's chosen provider or set a rate.

Commercial plans and state laws have their own access and continuity standards. The NAIC state insurance department directory helps locate the regulator for state-specific questions. Counsel should interpret disputed contract or legal obligations.

A fictional agreement matrix

Sofia's fictional payer approves a six-month network-gap arrangement. The practice reviews thirteen release fields. Eleven match the executed document. One clinician is missing from the named provider list, and the telehealth location remains undefined.

Agreement readiness is 11 of 13, or 84.6%. Services involving those two fields remain held while the parties seek a written amendment. The percentage measures contract configuration. It predicts no authorization, claim acceptance, adjudication, or payment.

The practice gives the family a summary of the confirmed cost-sharing term and open questions without turning the summary into a guarantee.

Avoid informal promises

A payer call saying “we can make an exception” is a lead, not an executed agreement. Record the representative, reference number, proposed terms, and next action. Delay representations about rates or in-network treatment until authorized signers complete the document.

Likewise, a provider should avoid treating an authorization notice as the SCA. Match each service line and effective date across both records.

Confirm who can bind each party

An SCA should be executed by people with authority to bind the payer and provider entity. A case manager, utilization reviewer, intake coordinator, or treating clinician may help negotiate facts without having signature authority. Record the legal names, signer roles, signature dates, and final effective date.

Compare the payer's countersigned copy with the provider's copy. If an email, rate sheet, or portal message appears to modify a term, ask whether the contract's amendment process accepts that form. Counsel should review ambiguous payment, termination, dispute, indemnity, or member-billing language. No staff member should fill a missing contractual term from memory or a different member's agreement.

Store the executed file in a restricted contract location while making the operational fields available to staff who schedule, authorize, bill, and reconcile the case.

Limit access to contract language and member information by workforce role, and record every later amendment with its signer, effective date, and affected services.

Monitor the term and claims

Create reminders for expiration, authorization renewal, rate updates, clinician additions, location changes, and unresolved claims. Preserve the agreement version that governed each service date.

Useful measures include agreements fully configured before service divided by agreements due; claims matching all SCA fields divided by claims released; and amendments open by age. Report agreements, members, clinicians, service lines, and claims separately.

Before the first service and each renewal, compare the signed agreement with the authorization and billing setup. Resolve any conflict in rates, codes, locations, dates, or member-billing terms in writing, and retain the version that governed each claim.