A single case agreement (SCA) is a one-client contract between an insurer and an out-of-network therapist, letting the client use in-network benefits with you. Payers grant SCAs for continuity of care after a plan change, when no in-network provider matches the needed specialty or language, or when the network can't offer timely access. The client initiates; you support with a letter and negotiate the rate.
Two situations produce most SCA requests: a long-term client changes jobs and the new plan doesn't have you in-network, or a prospective client's insurer has nobody within 40 miles who treats what you treat. Both have the same escape hatch, and the rate is one you negotiate, not one pulled from a fee schedule.
When will a payer actually grant one?
When denying it creates a documented access problem. Continuity of care is the strongest pattern: the client has been in treatment with you, their coverage changed through no choice of theirs, and interrupting an active episode of care is clinically defensible harm. Payers approve these because regulators and plan sponsors expect them to.
The second pattern is a network gap. Some payers call the request a "network gap exception" or "network exception," and Cigna publishes a network exception request form for exactly this. If the directory shows no in-network therapist with the required specialty (eating disorders, EMDR, a specific language) accepting new patients within a reasonable distance or wait time, the plan has an adequacy problem. Behavioral health networks fail these standards often enough that HHS has studied it at length, and some states set hard access standards in regulation.
What does not work: asking for an SCA because the client simply prefers you, or because you'd like the referral. Payers read those as rate-shopping and deny them fast.
Who makes the call: you or the client?
The client, first. The insurer's network obligation runs to its member, so a member saying "I can't find anyone in-network who can treat me" opens a case file that a provider's cold call never will. Have the client phone member services, ask for an SCA or network gap exception by name, and log every in-network provider they tried: names, dates, "not accepting new patients," quoted wait times. That call log becomes the evidence.
Your job is the second call and the paperwork: clinical justification, credentials, diagnosis and CPT codes, proposed rate, requested session count. The script and letter below cover both halves. Expect the payer to route you to provider contracting or the behavioral health subcontractor (often Optum for UHC plans, Carelon for many Anthem plans), and get a case or reference number on every touch.
The file is what carries these requests. A client call log showing that the only two in-network specialists for the diagnosis had 8- and 11-week waits can win a 20-session SCA at the therapist's full $165 fee in under three weeks, because that record makes denial indefensible.
What rate do you ask for?
Your full private-pay fee is the opening position; concede slowly. SCA rates generally settle somewhere between the payer's in-network fee schedule and your full fee; a common outcome is your fee minus 10 to 20 percent. Anchor high because two things ratchet downward from your opening number: this negotiation, and every future SCA with the same payer, since payers reference prior agreed rates as precedent.
Never open at or near the in-network rate to seem agreeable. If you'd accept the in-network rate, apply to the panel instead. Know the payer's typical in-network figure before the call, and know your walk-away number. The rates-by-payer comparison gives you the floor of the bargaining range. For continuity-of-care SCAs where you already set a fee the client paid privately, that fee is the natural and defensible ask.
Get the final agreement in writing before the first covered session: rate per CPT code, number of sessions or date range, authorization number, claims address or payer ID, and whether the client owes in-network or out-of-network cost sharing. A rate quoted by phone with no paper behind it is how clawbacks happen. And before anything else, confirm the plan is one the insurer actually controls. The benefits verification script sorts fully-insured plans from self-funded employer plans, where the employer's administrator makes the exception rules.
What else is an SCA good for?
Evidence. Every SCA a payer signs with you is the payer conceding, in writing, that its network needed you for that client. If you later apply to the panel and get the standard "network is closed" or denial-for-capacity letter, your SCA history is the strongest exhibit in a closed-panel appeal: "you've needed me four times in eighteen months; the gap is not hypothetical." Keep copies of every agreement, with dates and the stated reason for approval.
| Route | Covers | Rate | Scales? |
|---|---|---|---|
| SCA | One client, one episode | Negotiated, near your fee | No; renegotiated each time |
| In-network | All members | Fee schedule | Yes |
| Superbill (OON) | One client, ongoing | Client's OON benefit | Only for PPO clients |
SCAs don't scale, by design. Each one is its own negotiation, its own authorization, its own expiration date to track: workable for two or three clients, a part-time job at ten. If the same payer keeps generating SCA requests, that's the signal to pursue the panel itself; getting the credentialing application moving is the kind of thing paneled.ai exists for.
PART 1: CLIENT'S CALL TO MEMBER SERVICES (give this to your client)
"Hi, I'm a member calling to request a single case agreement (you might call it a network gap exception) for an out-of-network therapist.
My situation: [I've been in active treatment with this therapist and my plan changed on DATE / I searched your directory and found no in-network therapist who offers SPECIALTY-LANGUAGE accepting new patients within a reasonable distance; I contacted N providers, and the soonest opening was X weeks out].
The provider is [NAME, CREDENTIALS], NPI [NPI], phone [PHONE]. They are willing to work with you directly on the agreement.
Please open a case for this request and give me the case number. What documentation do you need, and what is the turnaround time?"
Write down: case number, rep name, date, everything they ask for.
PART 2: PROVIDER SUPPORTING LETTER (you send after the case is open)
Subject: Single case agreement request for member [NAME], case #[NUMBER]
To: [PAYER] Provider Contracting / Behavioral Health Network Management
I am writing in support of the single case agreement requested by your member [CLIENT NAME], DOB [DOB], member ID [ID], case #[NUMBER].
Provider: [LEGAL NAME, CREDENTIALS], License #[NUMBER] ([STATE]), NPI [NPI], Tax ID [TIN]
Clinical basis:
- Diagnosis: [ICD-10]. Treatment: [MODALITY], CPT [90837/90834], [FREQUENCY].
- [Continuity: The member has been in active treatment with me since DATE, with N sessions completed. Interrupting an active episode of care to transfer would risk SPECIFIC CLINICAL REGRESSION.]
- [Gap: The member documented contacting N in-network providers; none offer SPECIALTY-LANGUAGE with availability inside a clinically appropriate timeframe. My training in this area: CREDENTIALS/CERTIFICATIONS.]
Proposed terms:
- Rate: $[FEE] per CPT [CODE] session (my standard fee)
- Duration: [N] sessions from [DATE], with review before extension
- I will submit claims per your standard process once terms are executed.
Please send the agreement in writing, including the authorized rate, session count, authorization number, and the member's cost-sharing terms. I can be reached at [PHONE] / [EMAIL].
[NAME, CREDENTIALS]
FOLLOW-UP: call weekly with the case number until you have the agreement in writing. Do not begin billing under the SCA before the executed copy arrives.
Track the end date the day the agreement arrives. An SCA that quietly expires mid-treatment turns session 21 into an ordinary out-of-network claim, and the extension request a few weeks early is a much easier conversation with the client than that one.
Common questions
- What is a single case agreement in therapy?
- A single case agreement (SCA) is a one-off contract between an insurer and an out-of-network therapist covering one specific client's treatment at a negotiated rate, usually so the client pays in-network cost sharing. It exists only for that client and episode of care. It is not network membership.
- Who requests a single case agreement, the therapist or the client?
- The client opens the request by calling member services, because the insurer owes the network obligation to its member, not to you. The therapist then supports it with a letter covering clinical necessity, specialty fit, and the proposed rate. Requests that start with the member get traction; cold provider requests mostly don't.
- What rate should I ask for in a single case agreement?
- Anchor to your full private-pay fee and negotiate down no more than 10 to 20 percent. SCA rates typically land between the payer's in-network fee schedule and your full fee. Never open at the payer's in-network rate: that becomes the ceiling, and prior SCAs with the same payer set precedent.
- When do insurers approve single case agreements?
- Three fact patterns dominate: continuity of care (the client was seeing you before a plan change), no in-network provider with the needed specialty or language within a reasonable distance or wait time, and clinical urgency where restarting with a stranger is documented as harmful. The client's call log showing failed in-network searches is the strongest evidence.
- How long does a single case agreement last?
- Whatever the agreement says: commonly a set number of sessions or a date range, sometimes tied to an authorization. It doesn't renew by itself. Calendar the end date and request an extension a few weeks out if treatment continues, or sessions past the boundary become ordinary out-of-network claims.
The paneled.ai team · Credentialing specialists. We file and track insurance credentialing applications for behavioral health providers every day — these guides come from what we see go wrong (and right) in real applications.