How does an SCA benefit the patient and the practice?

The patient pays in-network copays/deductibles rather than massive out-of-network bills, while the practice secures guaranteed direct payment from the insurer at negotiated commercial rates (typically 100% to 140% of Medicare allowable).

How long does it take to execute an SCA?

Negotiating an SCA directly typically takes 48 hours to 10 business days depending on payer urgency, clinical necessity documentation, and peer-to-peer case management reviews. Emergency and continuity-of-care petitions can be expedited.

Can a successful SCA lead to permanent in-network paneling?

Frequently, yes. Demonstrating sustained patient volume and specialized clinical need through multiple SCAs provides powerful data to overturn closed panel rejections and secure permanent group contracts.

What information is needed to initiate an SCA negotiation?

We require the patient's insurance card (front and back), diagnosis codes (ICD-10), proposed CPT billing codes, treatment plan frequency/duration, and clinical notes highlighting the unique necessity of your practice.

Out-of-Network Revenue Recovery

Single Case Agreements (SCAs) & Out-of-Network Negotiation Services

Q: Can an SCA be negotiated retroactively for care already provided?

Yes, under specific clinical circumstances such as urgent hospital discharges, unexpected network departures, or documented emergency stabilization. We construct retroactive medical justification dossiers to obtain retroactive authorizations.

Q: What clinical specialties utilize SCAs most frequently?

Behavioral health (eating disorders, adolescent psychiatry, trauma/EMDR), ABA and autism clinics, oncology subspecialties, complex surgical procedures, and rare pediatric therapy disciplines frequently require SCAs due to commercial network shortages.

Q: What is a Network Adequacy Gap Exception?

A Gap Exception is an insurance authorization granted when an insurer cannot provide an in-network provider within state statutory travel distance (e.g., 30 miles) or appointment wait-time thresholds (e.g., 10–14 days), legally compelling the payer to authorize an out-of-network provider.

Treating a patient whose insurance network lacks specialized in-network providers? We negotiate directly with commercial payers and Medicaid MCOs to execute Single Case Agreements—securing in-network reimbursement rates and protecting patients from out-of-pocket balance bills.

Payer-by-Payer Negotiation

Rate Optimization

Continuity of Care Appeals

Emergency SCA Filing

100% Primary Source Verification (PSV)

24–48h Setup · Active 7–10d Follow-Ups

Dedicated Credentialing Specialist

Bi-Weekly Status Reports & Payer Logs

Negotiate an SCA Contract

Get your out-of-network patient approved with direct in-network commercial billing.

Practice / Provider Name *

Email Address *

Phone Number *

Target Insurance Payer *

SCA Clinical Driver *

Fast Turnaround · Flat Fee Pricing · Zero Claim Leakage

94.8%

SCA Accuracy Rate*

100-140%

Medicare Benchmark Rates

48-72h

Avg. Payer Engagement

24h

Internal System Setup

Clinical Indications

When & Why Healthcare Practices Need SCAs

When commercial payers maintain insufficient networks, federal and state parity laws mandate that patients receive accessible care without punitive out-of-network expense.

Continuity of Care Protections

When an existing patient's employer abruptly changes insurance carriers, an SCA ensures uninterrupted treatment with their trusted provider under established clinical relationship rules.

Network Adequacy Gaps

When a payer directory has no in-network providers with active openings within a 30-mile radius or 14-day appointment window, we force an out-of-network Gap Exception approval.

Highly Specialized Modalities

Specialized treatments such as ABA therapy, eating disorder IOP/PHP programs, TMS, specialized pediatric speech, or rare surgical procedures rarely have adequate in-network coverage.

Geographic & Rural Deficiencies

Practices operating in rural, micropolitan, or underserved regions where commercial insurance panels are technically closed but physically devoid of operating providers.

Interim Paneling Coverage

While your initial full insurance credentialing application is winding through a 90-day payer queue, an SCA bridges the revenue gap so you can bill immediately for active patients.

No Surprises Act Compliance

An executed Single Case Agreement eliminates balance billing liabilities, providing legal assurance that your agreed-upon contracted rate is paid directly by the insurance plan.

Negotiation Strategy

5 Pillars of Our High-Yield Single Case Agreement Process

We do not simply request permission—we construct formal clinical dossiers and fee schedule proposals that commercial medical directors approve.

Case Manager Engagement

We bypass general customer service queues, establishing direct communication with regional payer case managers.

Clinical Justification Dossiers

We craft persuasive clinical letters detailing specialized provider certifications and treatment plan efficacy.

Aggressive Rate Negotiation

We benchmark rates against commercial averages and Medicare schedules, targeting 100-140% Medicare allowable.

Duration Structuring

We ensure that the executed LOA clearly specifies authorized CPT ranges and multi-month duration windows.

Billing System Alignment

We provide your billing team with exact authorization numbers, formatting, and EDI routing rules.

Case Study: 6-Month SCA Package for a Pediatric Specialty Clinic Unlocking $140k

A pediatric speech/OT practice in Colorado had 12 children with ASD whose insurance switched to a closed regional plan. Families faced $2,500/month out-of-pocket bills. We submitted a Gap Exception petition. Within 8 days, the payer executed 12 SCAs at 135% of Medicare allowable, covering 100% of therapy costs.

$140k

Authorized Care

135%

Medicare Rate

8 days

Payer Execution Time

Payer Protocols

SCA Protocol by Major Commercial Payer

Every commercial insurer utilizes distinct contracting workflows, review committees, and rate negotiation benchmarks.

Commercial Insurance Payer	SCA Department Division	Exp Rate Target	Execution Time
Aetna / CVS Health	National Special Contracts	100%–130% Medicare	3–7 Days
Blue Cross Blue Shield	Local Plan Provider Network Ops	110%–140% Local Fee	5–10 Days
UnitedHealthcare / Optum	Care Advocacy & Gap Solutions	100%–125% Benchmark	48–96 Hours
Cigna / Evernorth	Utilization Management Review	105%–130% Contracted	3–7 Days
Humana	Network Development	100%–120% Medicare	4–8 Days

Execution Roadmap

Our 4-Phase Single Case Agreement Workflow

From patient intake to the first paid claim, we manage the entire end-to-end payer negotiation lifecycle.

Intake & Benefit Audit

We review the patient's plan tier, out-of-network deductible status, and document the specific lack of available in-network clinical specialists.

Proposal & Letter of Agreement

We draft a comprehensive SCA proposal packet including clinical necessity letters, proposed CPT billing codes, and our fee schedule benchmark.

Payer Negotiation Push

We conduct active phone and portal follow-ups with payer utilization managers and contracting specialists to secure optimal rate terms and duration.

Contract Execution & Billing

We review the final legal Letter of Agreement, coordinate provider signature, obtain the unique authorization number, and clear your billing team.

Frequently Asked Questions

Single Case Agreement (SCA) FAQs

What is a Single Case Agreement (SCA)?

A Single Case Agreement is a binding contract between an insurance payer and an out-of-network healthcare provider. It allows the provider to render specific medical or mental health care to an individual patient at agreed-upon in-network reimbursement rates, ensuring the patient only pays their standard in-network copay and deductible.

How does an SCA benefit both the patient and the practice?

For the patient, it eliminates catastrophic out-of-network deductible obligations and balance bills. For the provider, it guarantees direct electronic claim payments from the commercial insurer at premium contracted rates (typically 100% to 140% of Medicare allowable), eliminating collection risks.

How long does it take to negotiate and execute an SCA?

Standard SCA negotiations take between 48 hours and 10 business days depending on the payer's contracting queue and medical director review schedules. In urgent or crisis situations (e.g., hospital discharge or eating disorder stabilization), we submit expedited clinical petitions within 24 hours.

Can an SCA be negotiated retroactively for care already provided?

Yes, under specific clinical circumstances such as unexpected employer plan switches, emergency treatment, or documented failure of payer directories to disclose network status. We construct comprehensive retroactive justification packets to recover held claims.

What clinical specialties utilize SCAs most frequently?

Behavioral health (therapists, psychologists, psychiatrists, addiction IOP/PHP centers), ABA and autism clinics, pediatric subspecialties (speech, OT, PT), oncology, and specialized surgical disciplines frequently utilize SCAs due to severe commercial network capacity shortages.

What is a Network Adequacy Gap Exception?

A Gap Exception is an authorization granted when an insurance company cannot provide an in-network provider within state statutory travel limits (e.g., 30 miles) or clinical appointment wait-time thresholds (e.g., 10–14 days). By law, the payer must cover out-of-network care at in-network cost-sharing.

Can an SCA lead to permanent in-network paneling?

Yes! Demonstrating recurring patient demand and specialized clinical capabilities through multiple Single Case Agreements is one of the single most effective strategies to overturn a closed panel rejection and secure a full commercial group contract.

What documents are required to initiate an SCA negotiation?

We require the patient's insurance card (front and back), diagnosis codes (ICD-10), proposed billing codes (CPT/HCPCS), treatment frequency, and brief clinical notes explaining why an in-network provider cannot provide comparable care.

Stop Turning Away Out-of-Network Patients

Let our professional contracting team negotiate your Single Case Agreements and secure in-network reimbursements at premium rates.

Negotiate an SCA Today View Flat-Fee Pricing