Single Case Agreement Letter Template for Therapists

What Is a Single Case Agreement?

A single case agreement (SCA) is a negotiated contract between an out-of-network mental health provider and an insurance company that authorizes treatment for a specific client at a mutually agreed-upon reimbursement rate. Unlike full network participation, an SCA applies only to one client and typically covers a defined treatment period or number of sessions.

Insurance companies are most likely to approve SCAs when there is a documented network adequacy gap, meaning the plan does not have an in-network provider who can meet the client's specific clinical needs. This may occur when the client requires a particular therapeutic modality, language capability, or clinical specialization that is not represented in the plan's network.

SCAs are grounded in the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires that insurance plans provide mental health benefits comparable to medical and surgical benefits. When a plan cannot provide adequate in-network access to mental health services, members have a legal basis for requesting out-of-network coverage at in-network rates.

When You Need It

Single case agreements are appropriate in the following clinical and administrative situations:

• No in-network specialist available. The client requires a specific treatment modality (such as EMDR, DBT, or ERP) and no in-network provider is trained in that approach within a reasonable geographic distance.
• Continuity of care. A client has an established therapeutic relationship with you and switches to an insurance plan where you are not in-network. Disrupting treatment would be clinically contraindicated.
• Waitlist barriers. In-network providers in the client's area have waitlists exceeding 30 days, creating an access barrier for a client in acute need.
• Cultural or linguistic match. The client requires a therapist who speaks a specific language or has cultural competency that is not available in-network.
• Geographic limitations. The client lives in a rural area where in-network mental health providers are not within a reasonable travel distance as defined by the plan's network adequacy standards.

Before pursuing an SCA, verify that the client has out-of-network benefits, as some HMO plans do not cover any out-of-network services and will not consider SCAs.

Key Components

A successful SCA request includes the following elements:

1. Client identification and plan information. Member name, date of birth, member ID, group number, and the specific plan name.
2. Provider credentials. Your full name, license type and number, NPI, tax ID, practice address, and contact information.
3. Clinical justification. A clear explanation of why this specific client requires your services and why in-network options are insufficient.
4. Network inadequacy documentation. Evidence that you have attempted to find in-network providers, including names of providers contacted, dates of contact, and reasons they were unavailable or inappropriate.
5. Proposed treatment plan. Diagnosis, recommended treatment modality, session frequency, and estimated duration of treatment.
6. Requested reimbursement rate. Your proposed per-session rate and the CPT codes you will be billing.
7. Signature and date. The requesting provider's signature and the date of the request.

How to Write It Step by Step

Step 1: Verify the client's benefits. Call the number on the back of the client's insurance card and confirm whether the plan includes out-of-network benefits and whether SCAs are available for the plan type. Document the name of the representative you spoke with, the reference number, and the date of the call.

Step 2: Document the network search. Before submitting your request, conduct a thorough search for in-network providers. Use the insurance company's online directory, call at least three to five listed providers, and record the outcome of each contact. Common findings include providers not accepting new patients, having long waitlists, lacking the required specialization, or having incorrect contact information in the directory.

Step 3: Establish clinical justification. Write a concise but specific clinical rationale explaining why this client needs your particular expertise. Avoid vague statements like "the client prefers this provider." Instead, focus on clinical necessity: the specific diagnosis, the evidence-based treatment required, your training in that modality, and why the client cannot receive equivalent care from available in-network providers.

Step 4: Propose specific terms. State the CPT codes you will use, the session frequency, the estimated number of sessions, and the rate you are requesting. Being specific demonstrates professionalism and makes it easier for the reviewer to approve the request.

Step 5: Submit the request to the correct department. Most insurers have a dedicated department for SCAs, sometimes called "network adequacy," "gap exceptions," or "out-of-network exceptions." Ask for the correct fax number or portal submission process when you call to verify benefits.

Step 6: Follow up systematically. If you have not received a response within 10 business days, call the SCA department and reference your submission date. Document every follow-up contact. If the SCA is approved, obtain the agreement in writing before beginning treatment under the SCA terms.

Step 7: Track authorization details. Once approved, note the authorization number, approved date range, approved number of sessions, approved CPT codes, and the agreed-upon reimbursement rate. Include the authorization number on every claim you submit.

Common Mistakes

Failing to document the network search. The most frequent reason for SCA denials is insufficient evidence that in-network options were explored. Simply stating that you checked the directory is not enough. Provide specific names, dates of contact, and reasons each provider was unavailable or clinically inappropriate.

Using vague clinical justification. Phrases like "the client has a good rapport with this provider" or "the client prefers out-of-network care" are not clinical justifications. Insurers need to see a specific diagnosis, functional impairment, a named evidence-based treatment, and a clear explanation of why in-network providers cannot deliver that treatment.

Not verifying the plan type first. HMO plans and some EPO plans do not offer out-of-network benefits under any circumstances and will not approve SCAs. Always verify the plan type before investing time in a request.

Requesting an unreasonable rate. Requesting a rate significantly above the insurer's usual and customary rate for your area will likely result in a counteroffer or denial. Research local reimbursement rates before proposing your rate.

Starting treatment before the SCA is finalized. If you begin treatment before the SCA is approved and documented in writing, you may not be reimbursed for those sessions. Wait for written confirmation of the agreement terms before billing under the SCA.

Neglecting to reauthorize. SCAs typically cover a fixed number of sessions or a specific date range. If the client needs continued treatment beyond the authorized period, you must submit a new request with updated clinical documentation before the current authorization expires.

Not keeping a copy of the signed agreement. Always retain a copy of the fully executed SCA. If a claim is denied despite an active SCA, the signed agreement is your primary evidence for appeal.