Single Case Agreement (SCA)

What a Single Case Agreement is

A Single Case Agreement is a written, case-specific contract between a health plan and a provider. It typically applies when a member needs care from a provider who is out of network, or where the standard contract does not fit the service type or level of care.

For revenue cycle, a Single Case Agreement is a rate sheet and rulebook for one member and one episode. It spells out what the payer will treat as covered, what codes or levels of care are authorized, the allowed amounts, and any special billing instructions. It usually references the member ID, diagnosis, level of care, facility or clinician NPI, and the date span the payer is committing to.

In practice, SCAs sit alongside prior authorizations and the payer's general policy. They do not replace those items. The SCA modifies the usual network and reimbursement rules for this one case, and your team has to bill exactly inside those terms.

Why Single Case Agreements matter operationally

A Single Case Agreement is often the difference between full reimbursement and being treated as fully out of network. On a 30-day residential stay, the gap can be tens of thousands of dollars if the payer ignores the SCA or if your claim does not match the terms.

Operationally, SCAs matter because:

• They change expected reimbursement and contract status for specific patients.
• They usually set strict date and unit limits, so services outside those limits deny or underpay.
• They can require specific codes, modifiers, or revenue codes that differ from your internal defaults.
• They often depend on concurrent authorization, so units past the auth or SCA end date deny even if you have a signed agreement.

If SCAs are not centralized and codified in your RCM workflow, common failure modes show up fast: claims paid at default out-of-network rates instead of SCA rates, services past the SCA date span denied as CO-197 or CO-50, or audits and recoupments when billing exceeds agreed limits. For longer behavioral-health episodes, poor SCA control quietly distorts your net collection rate and days in AR.

How to use and read a Single Case Agreement

Operationally, treat a Single Case Agreement like a temporary mini-contract that your team must encode into your practice management or billing system.

Key elements to find and record when reading an SCA:

• Member and provider identifiers: member ID, subscriber, patient name, provider NPI and TIN, facility name.
• Coverage window: start and end dates, whether the SCA is episode-based (for a stay) or per service.
• Level of care and setting: residential, PHP, IOP, OP, telehealth, and any ASAM level references that drive code selection.
• Codes and units: covered CPT/HCPCS or revenue codes, daily vs per-session billing, maximum units or days.
• Rates and member cost share: per-diem or per-session allowed amount, how coinsurance, copays, and deductibles apply.
• Authorization linkage: required prior auth number, concurrent review requirements, and who reviews (medical vs behavioral health vendor).
• Billing instructions: which payer ID to use, any requirement to mark as in network, specific notes or identifiers to put in the claim remarks or authorization fields.

Once interpreted, the SCA needs to be:

• Stored where both clinical and billing staff can find it quickly.
• Translated into fee schedule entries or case-specific overrides in your billing system.
• Embedded into your scheduling and utilization review workflows, so staff know when the SCA expires or when re-negotiation is needed.
• Reflected in documentation, for example in a Supanote template field, so coders and billers can confirm level of care and auth against the agreement.

If the agreement is ambiguous, have your contracting or UR lead clarify with the payer in writing before you start or continue high-dollar services.

• Letting clinical teams admit an out-of-network residential patient based on a verbal assurance from the payer, then never obtaining a written Single Case Agreement or documenting the agreed rate, so claims pay at default out-of-network levels and the family is unexpectedly balance billed.
• Securing an SCA for 30 days of ASAM 3.5 residential at a per-diem rate, but billing day 31 and beyond without either an SCA extension or new agreement, which leads to CO-197 or CO-50 denials on the tail of the stay.
• Ignoring the specific codes and level-of-care language in the SCA and billing generic 90837 + H0015 instead of the per-diem revenue code the payer required, so the payer pays some units at lower outpatient rates and denies the rest as non-covered.
• Failing to load SCA-specific rates into the practice management system, so staff quote wrong patient responsibility and the payer correctly pays to the SCA rate but the patient statement shows inflated charges and triggers complaints and appeals.
• Not tying the SCA to the correct payer entity in cases with behavioral-health carve-outs, so claims go to the medical plan instead of the behavioral health vendor and deny repeatedly as CO-109 or CO-96 until the timely filing window is almost gone.

Single Case Agreements show up constantly in behavioral health because network coverage is often weaker for residential treatment, partial hospitalization, and intensive outpatient. Families push for in-network exceptions when your program is out of network, and payers respond with case-by-case SCAs instead of signing a full contract.

Carve-outs add another layer. A member may have medical benefits through one payer ID and behavioral-health benefits through a carve-out vendor. In that setup, the SCA often lives with the behavioral-health administrator, not the medical plan, and may specify very different rules for levels of care like ASAM 3.1 or 3.5. If your team bills the wrong entity or uses the wrong place-of-service or revenue code for the agreed level of care, you lose the SCA benefit and see out-of-network pricing or CO-109 denials.

Behavioral-health SCAs almost always tie to concurrent authorization. For long per-diem residential episodes, the SCA might approve a block of days at a negotiated rate, contingent on ongoing UR notes and continued-stay reviews. Units beyond either the SCA date range or the concurrent auth range are at high risk for denial or recoupment, even if the patient stayed. State Medicaid and MCO programs sometimes use single case or single-subject contracts where network capacity is limited for SUD or specialty adolescent programs, but those agreements are tightly controlled and must stay inside state policy and medical-necessity rules.

For PHP and IOP, SCAs are often used when the payer lacks contracted local programs for the age group or diagnosis mix you serve. The agreement may specify daily program requirements, staff credentials, and documentation standards. Weak documentation on group therapy notes or treatment plans can undermine medical necessity and turn what looked like secure SCA revenue into a post-payment audit problem months later.

AI can help with Single Case Agreements by reading payers' SCA letters, PDFs, and portal messages, then extracting the key operational details: patient identifiers, date ranges, levels of care, codes, and rates. An agent can crosswalk those details into your fee schedule and authorization records, flag conflicts with your usual coding patterns, and warn staff when scheduled services fall outside the SCA window or unit limits.

Supabill can assign an agent to watch every new SCA and authorization, codify the agreement into structured rules, and then compare submitted claims and 835 remittances against those rules. The denials agent can spot when a payer paid at default out-of-network rates instead of the SCA rate, classify the denial or underpayment using CARC and RARC codes, and tee up a targeted appeal with the SCA attached. The human team still owns negotiation with payers, deciding when to push for an SCA versus accepting out-of-network status, and handling nuanced medical-necessity disputes, since those rely heavily on clinical judgment and payer relationships.

Is a Single Case Agreement the same thing as prior authorization?

No. A Single Case Agreement is a case-specific contract that sets payment and coverage terms for one member and episode, usually when you are out of network. Prior authorization is a utilization management decision about whether a service is medically necessary and covered under a member's benefit. You can have an SCA that still requires prior auth, and you can have prior auth without any SCA. Operationally, you want both: a written SCA that defines rates and network status, and an authorization that confirms the payer agrees the treatment is medically necessary. The Healthcare.gov prior authorization glossary entry is useful for explaining this difference to patients and internal stakeholders. Source

When should a behavioral-health provider request a Single Case Agreement?

Request an SCA when a patient wants to use benefits with a payer where you are out of network, and there is a clear reason the payer should make an exception. Common triggers include: no in-network program at the required level of care or with needed specialty expertise, geography or capacity issues that make in-network options unrealistic, continuity-of-care needs when a patient is already engaged with your clinicians, or a state Medicaid or MCO requirement to cover services where local networks are inadequate. Your utilization review or intake staff should identify these cases early during benefits verification and request the SCA before or as close to admission as possible. Source

How should Single Case Agreements be referenced on claims?

There is no single national rule for indicating a Single Case Agreement on a CMS-1500 or UB-04 claim. Most commercial payers either tie the SCA to a prior authorization number, which you enter in the prior auth field, or they instruct you to include a specific reference number or "SCA" language in the claim remarks or notes. Your internal SCA intake process should capture any payer-specific billing instructions and translate them into claim edits or templates. Since CMS does not define a separate SCA code set in its billing manuals, you must follow the instructions issued in the payer's SCA letter or portal message. Source

Are Single Case Agreements allowed in Medicaid and Medicaid managed care?

Many state Medicaid agencies and Medicaid managed care organizations use single case or single-subject contracts in limited situations, especially when network adequacy is an issue for specific services such as residential SUD treatment or adolescent programs. The exact rules are state specific. Some states require SCAs to be tied to evidence of network gaps and to follow the same medical-necessity, rate-setting, and documentation rules that apply to other providers. Before relying on an SCA for Medicaid, check state manuals or the MCO's provider materials, and confirm in writing that the agreement complies with Medicaid policy. General Medicaid program rules and guidance are available at Medicaid.gov. Source

How long do Single Case Agreements last and can they be retroactive?

The duration of an SCA is entirely payer specific. Some cover a fixed date range, such as the first 30 days of a residential stay, while others cover an entire episode up to a maximum number of days or units. Retroactive SCAs are occasionally granted, especially when there were clear network adequacy issues, but payers are often reluctant to backdate exceptions far into the past, and timely filing rules still apply. For behavioral-health episodes, tie SCA end dates into your concurrent review calendar so you either discharge, request an extension, or negotiate a new agreement before you provide noncovered days that may later deny or be recouped. Source

• CMS
• Healthcare.gov - Network
• Healthcare.gov - Prior Authorization
• Medicaid.gov
• SAMHSA - Behavioral Health Treatment