A Single Case Agreement (SCA) is a contractual arrangement between a health insurance payer and an out-of-network healthcare provider for a specific patient. This contract defines the terms of service, including the agreed-upon reimbursement rate, for a limited number of visits or a defined period of treatment. The purpose of an SCA is to ensure the patient can access necessary, often specialized, medical services when an appropriate in-network provider is unavailable. This guide outlines the procedures for successfully requesting and managing an SCA.
Establishing Eligibility for an SCA
A successful SCA request requires clear justification for using an out-of-network provider. The primary justification is often a lack of network adequacy. This occurs when the insurer cannot provide a provider with the necessary specialization within a reasonable geographic distance or timeframe. The patient’s medical condition may necessitate a level of expertise or treatment modality not offered by local in-network options.
Documenting the medical necessity of the provider’s unique expertise is another strong justification. This requires demonstrating that the provider possesses specialized training or experience directly relevant to the patient’s complex diagnosis or treatment plan. The insurer must be convinced that the patient’s clinical outcome depends on receiving care from this specific individual. Continuity of care also supports an SCA, especially when a patient is mid-treatment and their long-term provider leaves the network. In these cases, the request allows the patient to complete their current course of therapy without interruption.
Essential Documentation for Submission
A comprehensive submission package is necessary to substantiate eligibility claims and facilitate the payer’s review process. The core document is the Letter of Medical Necessity (LOMN), typically authored by the treating physician. The LOMN provides a detailed clinical rationale for the requested services. This letter must explicitly connect the patient’s diagnosis and treatment plan to the specific qualifications of the out-of-network provider.
The provider’s professional credentials must be fully documented to verify their specialized expertise and licensure. This documentation includes a detailed curriculum vitae (CV), copies of current state licensing, and evidence of specialized certifications or training. The insurance company requires this information to credential the provider, ensuring they meet minimum quality standards, even for a single patient.
The financial component requires the out-of-network provider to submit their proposed fee schedule or requested rate for the specified services. This allows the payer to begin negotiation, often requiring the provider to accept a rate closer to the payer’s usual rate for similar services. Additionally, all relevant patient medical records must be included. These records, such as diagnostic reports and prior treatment summaries, provide objective evidence supporting the severity of the condition and the need for specialized intervention.
Navigating the Formal Request Process
The first procedural step involves accurately identifying the appropriate contact within the insurance company who manages network exceptions. This is often the utilization management department, the network exceptions team, or a dedicated SCA coordinator. Directing the submission to the incorrect department can lead to significant delays in the review process.
The responsibility for the formal submission package may fall to either the patient or the out-of-network provider, depending on the payer’s protocols. Often, the provider’s office staff manages the technical submission due to their familiarity with medical billing and contracting. Regardless of who submits, it is important to communicate whether the request is proactive (before treatment begins) or retroactive. Retroactive requests are generally discouraged but sometimes necessary in emergencies.
The submission package, including the LOMN, credentials, and fee schedule, must be sent using a method that provides confirmation of delivery, such as certified mail or a secure electronic portal. Noting the exact date of submission is important, as this date begins the contractual timeline for the payer’s response. Regular, formal follow-up is necessary after the initial submission to confirm receipt of all documents and monitor the review status.
During the review, the payer’s medical director or utilization review staff assesses the clinical justification against network adequacy and medical necessity criteria. If the clinical justification is accepted, the payer’s contracting team negotiates the reimbursement rate with the provider. This negotiation is essential, as the provider must agree to a rate the payer considers reasonable, often based on Medicare or in-network contracted rates, for the SCA to be finalized.
Post-Submission and Outcome Management
Once the SCA request is submitted, the insurance company initiates a formal review process with a defined timeline. This timeline ranges from a few days for urgent cases to several weeks for non-urgent requests. The payer uses this period to clinically review documentation and financially evaluate the proposed rate against internal benchmarks. Successful negotiation between the payer and the provider regarding the payment rate is the final step before formal approval is issued.
If the terms are mutually acceptable, the insurance company issues a formal written SCA document. This document explicitly states the approved services, the number of sessions, the duration of the agreement, and the agreed-upon reimbursement rate. Both the provider and the payer must sign this document, creating a binding contract for the patient’s care. Formal approval ensures the patient is protected from balance billing for the agreed-upon services.
If the SCA request is denied, the insurance company must provide a written explanation detailing the specific reasons for the refusal. This denial often triggers the option for an internal appeals process. The appeal allows the patient or provider to submit additional information or clarification to challenge the initial decision. Pursuing an appeal requires a focused response to the denial points, often involving a more detailed clinical justification or a modified fee proposal.