A single case agreement (SCA) is a contract between an insurance company and an out-of-network provider. It typically applies to a single client receiving a specific service for a set period of time at an agreed-upon rate.
For ABA providers, a single case agreement insurance arrangement can help a client use in-network benefits with an out-of-network provider when the payer agrees that the case meets its requirements. This is one reason many providers use outside ABA billing support when reviewing payer rules, documentation, and reimbursement terms.
SCA reimbursement rates vary by payer and are negotiated case by case. Depending on the payer and the strength of the clinical justification, rates may fall at, above, or below standard in-network levels — which is why understanding payer-specific SCA policies matters before entering into an agreement
Below are some of the questions providers commonly ask about SCAs, along with examples of situations where they may apply.
When Would a Patient Need a Single Case Agreement?
SCAs in behavioral health may be established when a patient cannot receive the same or comparable service from an in-network provider. If a patient needs a specialized service and an in-network provider is not available within a reasonable amount of time or proximity, an SCA can be considered to make up for the lack of availability.
These agreements may also be allowed if a patient has recently changed insurance providers and needs ongoing treatment with a specific provider that is now out-of-network.
A single case agreement for out-of-network care may also be supported by factors such as:
- Specialty services that are not available through nearby in-network providers.
- Language or cultural needs that affect the client’s access to appropriate care.
- Long wait times for in-network services.
- A need to preserve continuity of care during an insurance change or provider transition.
For ABA therapy, continuity of care can matter because treatment plans, clinical goals, and provider relationships are already established.
Why Would a Provider Want a Single Case Agreement?
A provider may want to continue working with a patient even after they have switched to an insurance provider that falls out of network. Two examples of general qualifications include the temporary transitional period until a specific provider is contracted as in-network with the new insurance or until a patient is transferred to another in-network provider.
When a provider is in the final stages of transitioning to an in-network status, they may obtain an SCA for a few months until contracting is completed.
It has not been uncommon for SCAs to compensate for services at rates that were more favorable than those available from in-network providers. Now, many payers offer SCA compensation at the highest network rate but allow patients continued access to their in-network benefits, resulting in less financial responsibility for the patient.
Single Case Agreement vs. Prior Authorization
The difference between a single case agreement and prior authorization is simple: prior authorization approves services, while an SCA sets the payment terms between the payer and an out-of-network provider.
Some payers may require both. A provider may need authorization for the service itself, as well as a separate agreement confirming the rate, billing rules, approved dates, and the number of sessions.
If a Provider Can Be Granted Single Case Agreements, Why Become In-Network?
Typically, insurance companies maintain a pool of contracted providers within a geographic area, and the payer will not offer SCAs if it believes enough providers are already available to meet its patients’ needs.
Other payers, such as Medicaid and other government entities, offer only in-network benefits, so SCAs are less likely to be an option. For smaller providers with fewer clients, it can be advantageous to be selective about which payer networks you wish to contract with.
Payers can also be slow or difficult to work with when processing out-of-network claims. Slow payment or difficulty with payment, even with documented contracts, is not unheard of. Generally speaking, these issues are eventually resolved, but providers should be mindful of deadlines and plan for extra administrative work before reimbursement is received.
What Else Do I Need To Know About Single Case Agreements?
SCAs can be a helpful alternative for patients and guardians when access to appropriate care through an in-network provider is limited. If a patient’s request for an SCA can explain and support in detail why a specific provider is better qualified to meet their medical needs than an in-network provider, this can help justify the need for an SCA.
A strong single case agreement example may include evidence that in-network options have long waitlists, are too far from the patient, or do not provide the specialized ABA services needed.
Single case agreements are often one part of a broader billing workflow. If you want the full picture of how claims, follow-ups, and collections connect, our guide to revenue cycle management for ABA therapy breaks down the process end-to-end.
Every Payer Handles SCAs Differently
There is no universal SCA process. Each payer sets its own rules for when a single case agreement is available, what qualifies as sufficient justification, and how the request needs to be submitted. So, a process that works smoothly with one insurer may not translate to the next.
There are payers that treat SCAs as a routine accommodation and will approve them fairly readily when a documented network gap exists. However, there are also those that treat SCAs as a last resort, reserved for cases where a provider can show (in detail) that no comparable in-network option is available within a reasonable distance or time frame.
In our experience, one of the biggest misconceptions is that submitting an SCA automatically leads to approval. In reality, single case agreements are never guaranteed, even when there appears to be a clear gap in a payer’s network. Approval often depends on how well the request aligns with the payer’s individual criteria and how thoroughly the supporting documentation demonstrates medical necessity and lack of suitable in-network alternatives.
We’ve also found that documentation quality plays a significant role in the review process. Missing provider information, incomplete clinical justification, or insufficient evidence of network limitations can all result in delays or denials before negotiations even begin.
How To Request a Single Case Agreement
When requesting a single case insurance agreement, it is necessary to obtain all required paperwork and have a clear understanding of the conditional SCA guidelines and terms. These may include authorization requirements, prior approval of services, billing requirements, payment terms, and the duration of services allowed.
Not all insurance companies provide a physical version of an SCA document. Clinical information should be documented and maintained to support medical necessity. Keeping complete records can help if additional justification is needed before services begin or during a post-service audit.
We’ve found that providers who prepare this justification early often have a smoother submission process. Payers may review nearby providers before agreeing to an SCA, so it helps to document wait times, location barriers, specialty needs, and continuity-of-care concerns.
Another factor providers should plan for is time. One pattern we’ve observed is that negotiation timelines vary considerably between payers. Some requests move through the approval process within a few weeks, while others require multiple rounds of communication before reimbursement terms are finalized. Missing paperwork or incomplete submissions can extend these timelines even further, making early preparation essential.
Finally, when looking at how to get an SCA from your insurance, be prepared for the extended time required to obtain it. As a provider, you will want to plan and coordinate services in advance to request approval. This way, once approval is granted, a plan of action is already set in place.
If an agreement to provide services during SCA consideration is in place, you will want to have a clear, well-written financial agreement with the patient, should the insurer come back and not cover the services provided.
Avoid These Common Single Case Agreement Mistakes
Even experienced ABA providers can encounter avoidable delays during the SCA process. Based on what we’ve seen working with providers across the country, a few recurring issues tend to create the biggest obstacles.
- Assuming an SCA will automatically be approved because there are limited in-network providers
- Submitting incomplete documentation or omitting evidence that supports medical necessity
- Waiting until services are scheduled before beginning the request process
- Overlooking payer-specific billing, authorization, or claim submission requirements
- Failing to confirm that SCA terms, authorizations, and claims all align before billing begins.
Single Case Agreements in Medical Billing
A single case agreement in medical billing affects far more than reimbursement for a single client. We’ve seen first-hand how delays during the SCA process create cash flow disruptions, increase accounts receivable, and require additional administrative follow-up when documentation, authorizations, or billing requirements are not aligned from the beginning. Managing SCAs carefully helps protect revenue while supporting uninterrupted access to care.
ABA CPT codes should be confirmed before billing begins. Some payers may approve only a specific number of sessions or require additional claim details. If the SCA terms, authorization, and claim information do not align, reimbursement may be delayed.
This is also where experienced billing support can make a difference. Providers comparing internal billing resources with outside support may find it helpful to review the criteria to consider when choosing a medical billing company. For more foundational billing guidance, our guide to ABA billing essentials covers common requirements for therapy practices.
Obtain Compensation for Single Case Agreements With Missing Piece ABA Billing
Missing Piece ABA Billing is experienced in helping providers obtain compensation for SCAs and tackle ABA insurance rate increases. We provide guidance in clinical documentation and handle the remaining administrative aspects, so your team can focus on patient care while we focus on reimbursement.
We can also provide insight into when it is more advantageous to remain out-of-network versus when it might be better to become an in-network provider.
To learn more about outsourcing your billing and revenue cycle management, talk to an expert at Missing Piece ABA Billing.
