A single case agreement is a written, case-specific arrangement between a payer and a nonparticipating provider. Its meaning depends on the exact document and the patient's plan.
An SCA may apply to defined services or a limited period. It is not a standard benefit or a promise of payment. Providers should verify every term before relying on one.
What is a single case agreement?
An SCA is a narrow written arrangement for a particular patient, provider, and situation. It may describe covered services, dates, claim steps, or payment terms. The contents vary by payer and agreement.
Related labels may appear in payer materials. These can include a letter of agreement or a network gap process. Do not assume those terms mean the same thing. Ask the payer what its document covers.
One verified example appears in BCBSTX's 2025 Medicaid provider manual. It says the plan may issue an SCA in certain cases. The example concerns covered treatment from a nonparticipating provider for a specified period. It reflects one payer program, not a universal rule.
How is an SCA different from prior authorization?
An SCA and prior authorization serve different administrative purposes. Neither guarantees payment. Prior authorization addresses a plan's approval requirements for a service. An SCA addresses a case-specific arrangement with a nonparticipating provider.
A payer may require one, both, or neither. The provider should ask whether separate approval is needed. The written response should identify the service, provider, dates, and claim instructions.
| Item | What it may address | What it does not guarantee |
|---|---|---|
| Single case agreement | A case-specific provider arrangement and its written terms | Payment, coverage, or a specific patient cost |
| Prior authorization | A plan's advance review requirement for a service | Final claim payment or an SCA |
| Standard out-of-network claim | Processing under the plan's ordinary rules | Network-level benefits or rates |
When might a payer consider an SCA?
A payer may consider an SCA when its rules allow care from a nonparticipating provider. A request might involve network availability, geography, continuity of care, or another plan-defined reason. The payer controls the process and decision.
The payer may request records or a treatment plan. The provider owns all clinical judgments and documentation. Administrative staff can coordinate the request without deciding medical necessity. Approval, partial approval, denial, or no agreement are all possible outcomes.
What terms should the provider verify?
The provider should get the agreement in writing and read every term. A verbal statement alone may not define the arrangement. The written document may address:
- the patient, provider, and services covered;
- effective and end dates;
- separate authorization requirements;
- claim submission and filing rules;
- payment or patient cost terms, if any; and
- dispute, amendment, or termination terms.
If a term is missing, ask the payer how the plan will handle it. Do not infer a rate, coverage decision, or balance-billing rule from silence. Contract terms, plan documents, and state or federal rules may affect the result. Counsel should review unclear legal or contract questions.
What should happen after the payer responds?
The next step depends on the written response. After approval, the provider should follow the agreement and any separate plan requirements. Keep the agreement, related approvals, claim records, and payer messages together.
After a denial, ask for the reason and any review path in writing. If the payer has not responded, follow up and document each contact. Do not assume an agreement exists without written confirmation.
Consider a simple example. A patient seeks care from a nonparticipating specialist. The provider asks the payer whether an SCA process is available. The payer sends written terms covering named services during set dates. The provider reviews those terms before deciding whether to accept the arrangement. The payer still processes each claim under the plan and agreement.
Before care starts, the office compares the written terms with the planned services. It checks whether a separate authorization is listed. It also records the payer's claim reference and filing instructions. If the written terms do not match the plan, the office asks for clarification.
After the service, the billing team follows the documented claim process. It keeps the agreement available for follow-up. If the payer processes the claim differently, the team can point to the written terms. The agreement still does not replace the plan's final claim review.
Frequently asked questions
Does an SCA guarantee payment?
No. It may state payment terms, but the provider must follow the written agreement. The payer still applies the plan, claim, and agreement rules.
Can a patient ask about an SCA?
Yes. A patient can ask whether the plan offers a case-specific process. The provider must independently review and accept any proposed terms.
This guide is general information, not legal, contract, medical, coding, or coverage advice, and not a promise that a payer will authorize, agree to, cover, or pay for care. Terms and processes vary by payer, plan, provider, service, state, and date.
