A single case agreement (SCA) is a patient-specific payment arrangement between an insurance company and an out-of-network healthcare provider. For therapists, it can allow an insurer to reimburse covered mental health services under agreed terms without requiring the clinician to become a permanent in-network provider.
A therapist may request a single case agreement when a client cannot obtain clinically appropriate care from an available network provider, needs continuity with an existing clinician, or requires specialized behavioral health services.
However, an SCA is not automatically approved because a therapist is licensed or a client prefers their services. The insurer must determine whether the circumstances meet the applicable plan requirements.
Even after approval, the therapist needs to confirm the covered services, reimbursement terms, effective dates, billing instructions, and the client's financial responsibility.
Understanding these details is especially important for licensed professional counselors (LPCs), licensed clinical social workers (LCSWs), marriage and family therapists (LMFTs), psychologists, psychiatrists, and group practices working with out-of-network clients.
This guide explains how single case agreements work, when insurers may consider them, and how to manage claims and payments correctly.
What Is a Single Case Agreement for Therapists?
A single case agreement is a limited arrangement establishing how an insurance company will cover and reimburse services provided by a particular out-of-network clinician to a particular patient.
Unlike a standard network contract, it generally applies to one course of treatment rather than all patients insured by the company.
The agreement can specify which clinician may provide treatment, the covered services, the reimbursement methodology, and the period during which the terms apply.
For example, a client may have insurance coverage for outpatient psychotherapy but be unable to access an appropriate in-network therapist.
The insurer may consider an agreement allowing a specific out-of-network clinician to provide covered therapy under negotiated payment terms.
The California Department of Health Care Services describes SCAs as arrangements covering one episode of care for one patient.
An SCA does not automatically make the therapist a participating provider for other members.
Is an SCA the Same as Insurance Credentialing?
No. Insurance credentialing and network contracting establish the provider's eligibility and participation under a broader payer relationship.
A single case agreement applies to a defined treatment arrangement.
A provider may still need to satisfy licensing, eligibility, exclusion-screening, and other payer verification requirements before an SCA can be approved.
However, completing an SCA does not automatically add the clinician to the insurer's permanent provider network.
The insurance credentialing process for therapists addresses ongoing payer participation, which is separate from patient-specific payment authorization.
When Can a Therapist Request a Single Case Agreement?
Therapists may request single case agreements when specific circumstances support the need for an out-of-network provider.
The insurer evaluates the request according to the client's plan, clinical needs, available providers, and applicable network requirements.
No Suitable In-Network Therapist Is Available
A client may need treatment but cannot locate a network therapist with the required qualifications or availability.
Relevant circumstances could include limited appointment access, a specialized treatment need, or another documented clinical requirement.
For example, a client requiring a clinician with experience in a particular behavioral-health condition might have difficulty accessing an appropriate specialist within the network.
The insurer may assess whether existing network providers can meet that need.
An inaccurate online provider directory alone does not prove an SCA is required, but documented attempts to access network care may support the request.
Continuity of Care Is Clinically Important
A client may already be receiving therapy from a clinician who is outside the client's current network.
Changing insurance plans, losing network access, or another coverage transition can create uncertainty about continued treatment.
An insurer may consider whether an interruption or change in provider would create a clinically significant concern.
UnitedHealthcare's 2026 Rocky Mountain Health Plans behavioral-health manual identifies certain continuity-of-care circumstances in which a single case agreement may be considered.
This does not establish automatic approval for every ongoing therapeutic relationship.
Specialized Treatment Requirements
A therapist may provide a service or possess qualifications that are particularly relevant to the client's treatment needs.
The insurer may consider whether an appropriate network alternative is available.
The request should explain the clinical reason for the proposed clinician rather than relying solely on preference or convenience.
A treatment recommendation can support an application, but the payer still controls its coverage and provider-review process.
Single Case Agreement vs Network Gap Exception vs Prior Authorization
These terms are related, but they describe different decisions.
Understanding the distinction is necessary because a therapist may receive one approval without receiving the others.
What Is a Network Gap Exception?
A network gap exception is an insurer's arrangement for accessing out-of-network care when appropriate in-network care is unavailable under applicable plan or legal requirements.
It may address network access, benefit treatment, or member cost-sharing arrangements.
However, the exact meaning and process vary by plan.
An approved network gap request does not necessarily establish a negotiated reimbursement rate for the selected therapist.
The administrator should verify whether the insurer also requires an SCA or another payment agreement.
What Is Prior Authorization?
Prior authorization is a payer review of whether specified services meet the applicable requirements before treatment, when advance approval is required.
An authorization might identify approved dates, services, or a treatment period.
It does not necessarily establish the provider's reimbursement amount.
For example, an insurer could approve outpatient psychotherapy from an out-of-network clinician while requiring a separate agreement to establish payment terms.
Other insurers may authorize the services without requiring a signed SCA.
Why an SCA May Be Required Without Prior Authorization
The reverse situation is also possible.
UnitedHealthcare's published guidance for certain Colorado Rocky Mountain Health Plans Individual Exchange products identifies outpatient psychotherapy codes, including 90832, 90834, 90837, 90847, and 90853, that do not require prior authorization for out-of-network providers but do require an SCA for payment.
That requirement applies to the specified plan arrangement. It is not a nationwide rule for every UnitedHealthcare product.
The important distinction: Approval to provide a service, approval to use an out-of-network clinician, and agreement on reimbursement terms should be confirmed independently.
Which Insurance Plans Require Single Case Agreements?
There is no universal rule requiring every out-of-network therapist to obtain an SCA.
Some insurance plans reimburse eligible out-of-network services under existing benefit terms.
Others require a specific agreement before particular services become payable.
Commercial Insurance Plans
A commercial insurer may consider an SCA when its network cannot meet a member's clinical needs or when the plan otherwise permits a patient-specific agreement.
The approval process may depend on the employer-sponsored or individual plan, network arrangement, and state requirements.
Two clients insured by the same national company may have different SCA requirements.
Carelon Behavioral Health Requirements
Carelon's November 2025 out-of-network provider guidance provides an important example.
It distinguishes commercial accounts with out-of-network benefits from those without them.
For certain eligible authorized services under commercial accounts without out-of-network benefits, Carelon requires a countersigned SCA. For eligible commercial accounts with out-of-network benefits, its published policy does not require a countersigned SCA in the same circumstances.
The guidance also identifies Medicare and Medicaid situations where a signed SCA is not required for eligible authorized services.
These rules are specific to Carelon's applicable policies and should not be generalized to other insurers.
Medicare and Medicaid Considerations
Original Medicare, Medicare Advantage, Medicaid fee-for-service, and Medicaid managed care have different participation and payment requirements.
A therapist should not assume a commercial SCA process applies to all government-funded coverage.
Applicable provider enrollment, beneficiary protections, and program requirements must be verified separately.
The existence of a patient-specific agreement does not override federal or state rules governing eligible providers and reimbursement.
What Information Is Required for a Single Case Agreement?
Insurers determine which documents and identifiers are necessary to evaluate an SCA request.
A complete submission usually involves information about the client, clinician, treatment, and proposed payment arrangement.
Client and Insurance Information
The payer may require:
Client's legal name and member identification number.
Insurance plan and applicable network.
Requested treatment dates.
Relevant benefit or authorization information.
Clinical explanation supporting the need for out-of-network care.
The provider should disclose protected health information only through authorized, secure channels and only as necessary for the legitimate review.
Therapist and Practice Information
Common information includes the clinician's professional name, license, individual NPI, practice address, and contact information.
A group practice may also need its organization NPI, tax identification number, and approved billing information.
The payer may conduct credential, eligibility, or exclusion screening even though the therapist is not seeking ordinary network participation.
Treatment and Reimbursement Details
The request may identify psychotherapy CPT codes, service location, requested appointment frequency, anticipated treatment period, and proposed reimbursement terms.
Examples of commonly used outpatient psychotherapy codes include 90832, 90834, and 90837.
The clinician must use the code that accurately represents the service provided.
An SCA does not authorize billing for services that were not performed or documented.
The exact requirements should be confirmed with the responsible payer department before submitting the request.
How to Request a Single Case Agreement From an Insurance Company
The process varies, but therapists can follow a consistent administrative sequence to reduce missing information and unclear approvals.
Step 1: Verify the Client's Coverage
Confirm that the insurance policy is active and identify the organization responsible for behavioral-health benefits.
The company on the insurance card may delegate behavioral-health administration to another organization.
Verify whether out-of-network benefits exist and whether the plan provides a pathway for requesting access to an out-of-network clinician.
The difference between private-pay and insurance-based therapy arrangements remains relevant when explaining potential client expenses before an agreement is confirmed.
Step 2: Identify the Responsible Department
Contact the payer using verified provider or member contact information.
Ask which department handles single case agreements, network exceptions, or out-of-network behavioral-health arrangements.
Do not assume that the general claims department has authority to approve the agreement.
Record the contact date, reference number, and instructions received.
Step 3: Establish the Reason for the Request
Provide an accurate explanation of why the selected therapist is clinically appropriate and why the client's needs may not be adequately addressed through available network options.
Relevant documentation may include appropriate treatment recommendations, demonstrated access difficulties, or clinical continuity considerations.
The explanation should be specific to the client's circumstances.
Step 4: Confirm Authorization Requirements
Ask whether the proposed treatment requires prior authorization and whether the SCA request can be reviewed at the same time.
Obtain separate confirmation for each required approval.
Do not assume an authorization number establishes the agreed reimbursement rate.
Step 5: Submit the Required Documentation
Use the insurer's approved submission method.
Some payers provide electronic workflows, while others use designated forms or contracting correspondence.
Submit only the information required for the request.
Incomplete identifiers or missing clinical information can delay the review.
Step 6: Review the Proposed Agreement
If the insurer offers an SCA, review its terms before accepting.
Confirm the provider, client, service codes, dates, payment terms, and billing instructions.
Clarify uncertain provisions with the payer before treatment is furnished under the proposed arrangement.
Step 7: Obtain Written Confirmation
Retain the final agreement and any required authorization records.
Where signatures are required, confirm that the agreement has been accepted by all necessary parties.
An unsigned draft or verbal discussion should not automatically be treated as an executed agreement.
Carelon's published process, for example, includes electronic signature and countersignature procedures for circumstances requiring a signed SCA.
Step 8: Verify Billing Instructions Before the First Claim
Confirm the payer ID, submission method, billing-provider identifiers, and any required reference information.
Determine whether reimbursement is sent to the clinician, group organization, or another approved recipient.
These details should be established before the first claim is submitted.
What Should Therapists Verify Before Signing an Agreement?
A single case agreement should provide enough information to determine what services are payable and how the insurer will process claims.
The wording matters because a general statement of approval may not resolve later payment disagreements.
Covered Services and Treatment Period
Identify the approved CPT codes, service settings, number of visits or other limits, and effective dates.
Confirm whether telehealth services are included when applicable.
A service outside the agreed period may not qualify for the same payment terms.
Reimbursement Rate and Payment Methodology
Determine whether the agreement establishes a fixed allowed amount, references a fee schedule, or uses another reimbursement calculation.
Do not assume the insurer will pay the therapist's full private-pay fee.
A written rate is particularly important when the practice needs to compare expected and actual reimbursement.
This differs from the broader process of negotiating reimbursement rates under ongoing insurance contracts, which concerns general network participation rather than one client's treatment.
Client Financial Responsibility
Confirm the applicable deductible, copayment, coinsurance, and any restrictions on additional billing.
An SCA does not automatically eliminate client cost sharing.
It also does not create an unlimited right to balance bill the client.
The applicable agreement, insurance benefits, state law, and federal protections determine the permissible amount.
Claim Filing and Payment Terms
Verify where claims should be submitted, whether special identifiers or attachments are required, and which filing deadlines apply.
Identify any requirements for extensions, payment disputes, or corrected claims.
Keep the final terms in a secure administrative record associated with the relevant client.
How to Bill Insurance Under an Approved Single Case Agreement
Billing under an SCA requires the practice to match the claim with the approved provider, covered services, and dates.
The agreement governs the relevant reimbursement arrangement, but it does not replace accurate claim documentation.
Confirm the Correct Billing Identity
For a solo therapist, verify the individual NPI and tax information recognized by the payer.
For a group practice, confirm whether the agreement names the organization, individual rendering clinician, or both.
The identifiers on the claim should match the applicable payer instructions.
A group organization should not assume that an SCA issued for one therapist applies to another clinician.
Use the Approved Service Codes
The claim must accurately report the service performed.
For example, CPT 90834 and CPT 90837 describe different psychotherapy time ranges.
The therapist must document the service and use the correct code.
If the SCA specifically covers 90834, the practice should not assume that 90837 will be reimbursed at the same rate.
Additional services may require separate approval or an amended agreement.
Submit Through the Approved Channel
An insurer may accept electronic claims through a clearinghouse, require a particular payer destination, or specify another submission method.
The practice should follow the instructions provided for the approved arrangement.
A superbill is not automatically a substitute for a claim submitted under an SCA.
The separate out-of-network superbill process generally involves providing documentation for the client to submit.
An SCA may establish a direct provider-payment arrangement with different requirements.
How Does SCA Billing Work in SimplePractice?
SimplePractice confirms that out-of-network clinicians can submit insurance claims under single case agreements.
However, SimplePractice does not negotiate or obtain those agreements on behalf of therapists.
The insurer must establish the SCA separately.
Before filing electronically, the clinician may need to register with the payer as a nonparticipating provider.
In SimplePractice, the administrator should verify the client's insurance information, rendering clinician, billing-provider identifiers, CPT codes, diagnosis information, and applicable payer connection.
Confirm how the payer expects any SCA or authorization reference to be supplied. The required claim field or supporting documentation can differ by insurer.
A configured insurance claim does not prove the SCA is active in the payer's adjudication system.
The SimplePractice billing administration process includes related responsibilities such as claim monitoring, payment tracking, and account reconciliation.
Example of Single Case Agreement Reimbursement for Therapy
Consider a hypothetical therapist who receives an SCA covering eight psychotherapy appointments.
The agreement establishes an allowed amount of $130 per eligible session.
The client's applicable cost-sharing responsibility is $25 per session.
If the claim is otherwise payable, the financial breakdown could be:
Agreed allowed amount: $130.
Client responsibility: $25.
Insurer payment: $105.
Total expected collection: $130.
For eight payable sessions, the total allowed revenue would be $1,040.
This example assumes all eight sessions satisfy the approved agreement and applicable coverage requirements.
The therapist should not automatically collect the full $130 from the insurer and an additional $25 from the client.
If the insurer processes the claim using a lower rate, the billing administrator should investigate before changing the expected balance.
All amounts are illustrative, not published payer reimbursement rates.
Why Are Single Case Agreement Claims Denied?
An approved agreement reduces certain payment uncertainties, but it does not guarantee every submitted claim will be paid.
Several errors can prevent reimbursement under the intended terms.
The Agreement Was Not Active on the Service Date
A claim may fall outside the approved period.
The therapist should compare the actual appointment date against the agreement's effective dates.
Do not assume the insurer will approve earlier services retroactively.
The Claim Uses an Unapproved Provider or CPT Code
The payer may reject or deny a claim when the rendering clinician, billing organization, service code, or setting differs from the agreement.
A therapist changing group practices should confirm whether the existing arrangement remains valid.
The Payer Cannot Identify the SCA
An agreement may be approved by one department but not correctly associated with the claim-processing system.
The billing administrator may need to provide the SCA reference or confirm that the insurer loaded the terms properly.
Authorization Requirements Were Not Satisfied
If the plan requires prior authorization in addition to an SCA, missing authorization can create a separate payment problem.
An SCA alone does not automatically waive clinical review requirements.
The Claim Was Filed Late
Timely filing limits differ among payers and plans.
Carelon's published out-of-network guidance includes a general 90-calendar-day filing period for specified authorized services, subject to applicable plan-manual and state-specific exceptions.
That is not a universal deadline for all SCA claims.
The practice should record the actual filing limit associated with the agreement.
What Happens When Insurance Pays Less Than the Agreed Rate?
An SCA underpayment occurs when an insurer processes an eligible claim below the amount required by the applicable agreement.
The first step is confirming that the claim falls within the agreement's covered services, dates, and provider terms.
Next, compare the electronic remittance or explanation of benefits with the agreed payment methodology.
A lower insurer payment does not always mean the allowed amount is wrong.
For example, the payer may correctly assign a portion of the allowed amount to the client's deductible.
The administrator must separate insurer payment from total allowed reimbursement.
If the actual allowed amount is incorrect, the practice should contact the payer's claims or provider-resolution department.
Supporting information may include the final agreement, claim reference, service date, remittance, and expected calculation.
The process for reviewing payer fee schedules and identifying underpayments addresses the financial comparison involved.
If the payer does not correct the discrepancy, follow its applicable provider dispute or appeal procedure.
Do not resubmit a duplicate claim without establishing whether correction, reconsideration, or formal appeal is required.
Can a Single Case Agreement Be Extended for More Therapy Sessions?
Some insurers permit extensions when continued treatment meets the applicable requirements.
However, an extension is not automatic.
The therapist may need to submit updated clinical information, explain the continuing need for treatment, or request approval for additional dates or sessions.
Carelon's guidance allows requests for certain out-of-network authorization date extensions through the member's plan contact or assigned clinical team.
An approved authorization extension does not necessarily mean every SCA payment term is extended in the same way.
The administrator should verify both the updated treatment approval and the applicable reimbursement arrangement.
For example, if an agreement covers eight sessions and the client needs four additional appointments, the practice should establish whether the insurer requires an amendment, additional agreement, or revised authorization.
Continuing treatment without confirming coverage can create financial uncertainty for the therapist and client.
How Do Group Practices Manage Single Case Agreements?
Group practices need an organized process because SCAs often apply to specific clients and clinicians rather than an entire practice.
The administrator should identify which rendering therapist is approved, the associated organization, the applicable payer, and the agreement's effective period.
Maintain a Patient-Specific SCA Record
Useful administrative fields include:
Insurance payer and plan.
Client and approved clinician.
Billing NPI and tax information.
Agreement or authorization reference.
Approved CPT codes.
Reimbursement amount or methodology.
Effective and expiration dates.
Approved session limits.
Claim submission instructions.
Extension and follow-up status.
These are recommended tracking fields, not a federally standardized SCA form.
Monitor Sessions Before the Agreement Expires
Track services provided against the applicable approved period and visit limit.
An upcoming expiration should be identified before appointments exceed the authorized arrangement.
For organizations handling several payer relationships, the broader administrative coordination of mental health practice billing can support consistent recordkeeping and responsibility assignment.
The clinical decision to continue treatment remains separate from the insurer's payment approval.
Reconcile Each Claim Under the Correct Terms
After submission, compare the payment report with the SCA.
Investigate missing payments, incorrect allowed amounts, and differences between the insurer's stated responsibility and the practice's records.
A group practice should not apply the agreement's rate to unrelated patients or assume that a temporary SCA creates permanent network participation.
Conclusion
Single case agreements can establish patient-specific reimbursement arrangements for therapists providing certain out-of-network mental health services.
The most important requirements are identifying the correct insurance process, documenting the clinical and network circumstances, confirming the agreement's terms, and submitting claims that match those terms.
Prior authorization, network exceptions, and SCAs are related but separate decisions. Therapists should not treat one approval as proof that every financial requirement has been satisfied.
For solo clinicians and group practices, accurate records of approved services, dates, reimbursement amounts, and claim outcomes can reduce preventable billing disputes.
The applicable payer agreement and plan requirements ultimately determine how the arrangement works.
Frequently Asked Questions
Can a therapist request a single case agreement without being in-network?
Yes. Single case agreements are designed for certain out-of-network care arrangements. However, the insurer determines eligibility, required provider screening, covered services, and reimbursement terms. Being licensed and out-of-network does not guarantee approval.
Does a single case agreement guarantee insurance reimbursement?
No. Claims must still comply with the agreement, applicable benefits, clinical requirements, billing instructions, and submission deadlines. Approval of an SCA does not guarantee payment for every service or an unlimited number of appointments.
How long does it take to get a single case agreement approved?
There is no universal approval timeline. Processing depends on the payer, insurance plan, required documentation, clinical review, and contracting procedures. Therapists should obtain the plan-specific process and verify approval before relying on the agreement for scheduled care.
Will insurance cover a therapist's full private-pay rate under an SCA?
Not necessarily. The agreement may establish a fixed reimbursement amount or another payment calculation. The insurer is not automatically required to pay the therapist's standard private-pay fee. Client cost sharing must also be determined from the applicable benefits and agreement.
Can a therapist request an SCA after treatment has started?
A request may be possible, but retroactive approval is not guaranteed. The payer may limit coverage to specific effective dates or require approval before services begin. Therapists should verify whether earlier sessions are eligible rather than assuming a later agreement will cover them.
Is a single case agreement the same as a letter of agreement?
Terminology varies. Some payers use the terms interchangeably. Other programs distinguish a single case agreement for one patient's episode of care from a broader letter of agreement covering additional patients or treatment periods. The actual scope of the document controls the arrangement.
Can an SCA cover telehealth therapy?
It may, depending on the payer's approval and the plan's requirements. The therapist should confirm whether virtual services are included and use the appropriate place-of-service code and any required modifiers. Telehealth coverage should not be assumed from an agreement that addresses only in-person services.
Can a single case agreement be transferred to another therapist?
Not automatically. An SCA may identify a specific approved clinician. If the client changes therapists, the insurer may require a new review or amendment. A group practice should obtain confirmation before submitting claims under another rendering provider.
