Single Case Agreements: How Providers Negotiate One-Patient Coverage and Protect Payment

A single case agreement, or SCA, is a patient-specific arrangement under which a health plan and an out-of-network provider agree on terms for a defined course of care. It does not make the provider a network provider. It creates a narrow arrangement that covers one patient and the services named in the agreement.

Public payer and regulator materials treat SCAs as something distinct from network participation. California's Department of Health Care Services (DHCS), for example, lists single-case agreements alongside contracts and letters of agreement as ways a Medi-Cal managed care plan can establish a relationship with an out-of-network provider so a member can continue care. Health Net's Medi-Cal rate FAQ is more explicit: providers on single case agreements or letters of agreement do not meet the state's definition of network providers for the purposes of its targeted rate increase.

For providers, the hard part is usually not the definition. It is making sure the agreement is precise enough, and reflected clearly enough in the payer's operational systems, that the eventual claim adjudicates under the negotiated terms.

Why do single case agreements exist?

Health plans ordinarily pay participating providers according to network contracts and members' benefits, but individual patients do not always fit neatly into the available network. An out-of-network provider may be considered for a patient-specific arrangement when specialized clinical needs, network availability or continuity of care make the ordinary network inadequate for a particular case.

California's managed care rules illustrate the continuity-of-care version. Under DHCS All Plan Letter 23-022, which covers members transitioning from Medi-Cal fee-for-service into managed care, when the member's existing provider is not in the plan's network, the plan must contact the provider and make a good-faith effort to enter into a contract, letter of agreement, single-case agreement or other relationship to establish continuity of care. Network availability cuts the other way, too: Anthem's Ohio Medicaid single case agreement FAQ states that Anthem may deny out-of-network requests if providers are available in network.

Whether a payer offers an SCA, and under what circumstances, is therefore specific to the payer and plan. It should not be presented to a patient as something the provider can obtain unilaterally. An SCA is an agreement, and both sides have to accept the terms.

An SCA is not the same thing as prior authorization

This distinction is critical. Authorization addresses whether the payer has approved a service under the patient's coverage; a single case agreement sets the contractual and payment terms for the out-of-network provider on that case.

The two can interact, but one is not proof of the other. Anthem's Ohio Medicaid FAQ, for example, requires out-of-network providers to submit a prior authorization request as well as the state forms that accompany a single case agreement request: two processes, two records. A provider who hears "the case is authorized" and assumes the reimbursement arrangement is finished is taking an avoidable risk, because it may not be.

The agreement needs to identify more than a rate

The negotiated rate gets the most attention because it drives expected reimbursement, but a useful SCA needs enough specificity to survive the claims process. Depending on the arrangement, that can include:

• patient and member ID;
• payer and plan;
• provider or facility;
• billing entity;
• tax ID and NPI;
• service or procedure codes;
• modifiers where material;
• approved units or visits;
• place of service;
• start and end dates;
• authorization number;
• negotiated rate or payment methodology;
• member cost-sharing treatment;
• billing instructions;
• claim submission destination;
• timely filing requirement;
• documentation requirements;
• contact or department responsible for agreement issues.

The exact terms vary, but the principle does not. If you expect the claims system to act on a term later, that term should be identifiable and documented now.

The negotiated agreement and payer claims system have to meet somewhere

This is where single case agreements become a revenue cycle problem rather than merely a contracting problem. Imagine that a payer representative agrees to a patient-specific rate and the provider receives written confirmation. Care begins, the provider submits the first claim, and the claim processes at the ordinary out-of-network rate or denies as nonparticipating. The agreement exists; the adjudication did not reflect it.

At that point the provider holds two separate facts. The contractual fact is that the parties agreed to specific terms. The claims fact is that the payer's adjudication system did not apply them. Resolving the gap requires enough documentation to connect the claim back to the agreement, which is why a successful SCA workflow has to continue past signature.

Before treatment, verify that operational setup is complete

Where feasible, confirm the implementation details before the first affected claim goes out. That can mean asking:

• Is the agreement associated with the member?
• Is it associated with the correct billing and rendering provider identifiers?
• Does the payer have the correct effective dates?
• Is an authorization also required?
• Are all expected codes covered by the agreement?
• Where should claims be submitted?
• Does the claim require an agreement, authorization or reference number?
• Is there a special billing instruction?
• Who handles discrepancies if the claim does not price correctly?

Provider setup can be its own administrative step. Anthem's individual and commercial provider site, for example, publishes a registration and update form for non-participating and single case agreement providers, and notes that the process is moving to Availity. Not every payer works this way, but the example makes the point: an SCA is not always finished when someone signs a PDF.

Rate language needs to be unambiguous

There is no responsible public benchmark for what an SCA "should" pay. Rates vary by market, service, provider, patient, payer and negotiating context. Rather than relying on unsupported rate expectations, concentrate on removing ambiguity from the agreement itself.

"80%," for example, means very little unless the denominator is clear. Eighty percent of what: billed charges, a payer fee schedule, Medicare, or another contracted amount? A flat case rate likewise needs a definition of what it includes. Any term that requires interpretation during adjudication is a future dispute waiting to happen.

Verify patient responsibility, too

An agreement between provider and payer can affect the patient's financial exposure, but the effect depends on the agreement and the benefit design. Do not assume an SCA eliminates all out-of-network cost sharing or converts every benefit into ordinary in-network treatment. Before quoting costs to the patient, verify what the payer has actually agreed to and how the member's benefits will be applied. That is a benefits verification question as much as a contracting one.

The written record should separate the payer's payment terms, the member's cost-sharing terms, and any amount the provider may bill the patient. That separation matters most for high-cost or ongoing care, such as ongoing behavioral health treatment. See behavioral health prior authorization for the authorization side of that workflow.

Track the authorization and agreement as separate objects

A simple operational improvement is to stop storing an SCA as a miscellaneous note inside an authorization record. Track both, and link both to the claim.

Authorization record

Capture:

• authorization number;
• authorized service;
• codes;
• units;
• dates;
• clinical limitations.

Agreement record

Capture:

• agreement identifier;
• contracted parties;
• negotiated reimbursement term;
• patient;
• applicable services;
• effective dates;
• billing instructions.

Keeping them separate makes it much easier to work out why a claim failed. Was the service outside the authorized date range? Was the authorization valid but the negotiated rate missing? Was the agreement attached to one TIN while the claim came from another? Was a code performed that was never included? A single note saying "SCA approved" answers none of those questions.

Audit the first claim rather than assuming the setup worked

For recurring treatment under an SCA, the first adjudicated claim is a useful test. Compare the remittance advice against the agreement:

• billed services;
• allowed amount;
• payer payment;
• contractual adjustment;
• patient responsibility;
• negotiated SCA terms.

If the result does not match the agreement, investigate immediately. Waiting until ten or twenty encounters have processed incorrectly turns one configuration problem into a reconciliation project, and every week of delay draws down the timely filing and dispute windows on the claims involved.

Where the payer says the agreement is in place but claims are still mispricing, preserve the agreement, the authorization, the claim number, the remittance, the payer interaction reference, the representative's response and your expected-rate calculation. The goal is to make the discrepancy provable without reconstructing the case from scratch. Structured claim status follow-up that records who said what, and when, is what makes that possible.

Know when an SCA is becoming the wrong tool

A single case agreement is designed to be narrow. If a provider keeps needing patient-by-patient agreements with the same payer, the administrative burden may signal that a broader arrangement deserves consideration. Payers use several forms of out-of-network relationship (California's continuity-of-care rules, for instance, name contracts, letters of agreement and single-case agreements side by side), and the options, terminology and thresholds differ by payer and program. Repeatedly rebuilding an identical one-patient arrangement may point to a contracting problem rather than an individual exception.

Getting the agreement is only half the job

The best single case agreement is not simply one that gets signed. It is one whose terms translate cleanly into authorization, billing and claims operations. For providers, that means treating the workflow as a chain:

patient need → payer approval process → negotiated agreement → operational setup → service → claim → payment reconciliation

A failure anywhere in that chain can make a perfectly legitimate agreement look useless. The objective is not just to negotiate coverage for one patient, but to make the documentation and payer setup precise enough that the eventual claim is recognized and paid on the terms both sides actually accepted.

FAQ

What is a single case agreement in insurance?

A single case agreement is a patient-specific agreement between a payer and an out-of-network provider that establishes coverage and payment terms for a defined case or course of treatment.

Does a single case agreement make a provider in-network?

Not generally. It is typically a limited arrangement for the specified patient and services rather than a network participation contract. Some payers say so directly; Health Net's Medi-Cal FAQ, for example, says providers on SCAs do not meet the state's definition of network providers for its targeted rate increase.

Is a single case agreement the same as prior authorization?

No. Authorization and contractual payment terms are different issues, although a payer's process may require both.

What rate should a provider negotiate?

There is no reliable public benchmark. The appropriate rate and methodology depend on the specific agreement and negotiating context. What a provider can control is making the rate language unambiguous.

Sources

All retrieved October 5, 2026.

• California Department of Health Care Services, All Plan Letter 23-022, "Continuity of Care for Medi-Cal Beneficiaries Who Newly Enroll in Medi-Cal Managed Care from Medi-Cal Fee-for-Service, on or After January 1, 2023" (August 15, 2023): https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2023/APL23-022.pdf
• Health Net, "Medi-Cal Targeted Rate Increase FAQs": https://www.healthnet.com/content/healthnet/en_us/providers/medi-cal-tri/faqs.html
• Anthem Blue Cross and Blue Shield, "Ohio Medicaid Single Case Agreement FAQ" (provider bulletin, June 2023): https://providers.anthem.com/docs/gpp/OH_CAID_SingleCaseAgreementFAQs.pdf?v=202302092254
• Anthem, "Provider Maintenance & Demographic Updates" (Individual & Commercial): https://www.anthem.com/provider/individual-commercial/maintenance-demographic-updates