Single-Case Agreements: Getting Paid While the Panel Stays Closed

A closed panel does not always mean you cannot treat a plan's members and be paid for it. When a member needs care the plan's network cannot provide, many plans will sign a contract for that one patient: a single-case agreement (also called an SCA, a case agreement or an out-of-network exception). It sets the rate, the services and the time period for one person. For a provider in the middle of a network dispute, it keeps established patients in care and builds a record that the network has a gap.

Where does a plan's duty to pay out of network come from?

No federal regulation uses the phrase "single-case agreement." The duty behind it does exist, in several places:

• Medicaid managed care. "If the provider network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of network for the enrollee, for as long as the" plan's network "is unable to provide them" (42 CFR 438.206(b)(4)). The plan must require out-of-network providers to coordinate with it for payment and must ensure the cost to the enrollee "is no greater than it would be if the services were furnished within the network" (438.206(b)(5)).
• Medicare Advantage. Coordinated care plans must "arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollee's medical needs" (42 CFR 422.112(a)(1)(iii)).
• Texas PPO and EPO plans. "If services are not available through a preferred provider within a designated service area," the insurer must reimburse a nonpreferred provider "at the same percentage level of reimbursement as a preferred provider would have been reimbursed" (Tex. Ins. Code 1301.005(b)). That does not apply when the insured simply prefers an out-of-area provider for convenience (1301.005(c)).
• New York managed care. If an insurer "does not have a health care provider in the in-network benefits portion of its network with appropriate training and experience to meet the particular health care needs of an insured," it must refer the insured to an appropriate provider under an approved treatment plan "at no additional cost to the insured beyond what the insured would otherwise pay" in network (N.Y. Ins. Law 4804(a)).

Other states have their own versions, and self-funded employer plans follow their plan documents. Check your state on the network access laws index.

When is a request likely to succeed?

The legal duties above turn on one fact: the network cannot provide the service to this member. Requests are strongest when:

1. The patient is already in treatment with you and a change of provider would disrupt care.
2. No in-network provider within a reasonable distance is accepting new patients, shown by a dated call log of the plan's own directory. See documenting an access gap.
3. You offer something the network lacks: a language, a specific treatment approach, an age group, a subspecialty.
4. The member asks too. Many plans start a network exception from the member services side. A member's own request, made through the plan's process, often moves faster than a provider's.

A request is weak when several in-network providers nearby have openings within the plan's wait standards. In that case the plan can reasonably say its network can provide the care.

What should the request contain?

• member name, ID and date of birth, sent only through the plan's secure channel for that purpose;
• your NPI, tax ID, license and practice address;
• the service, the expected frequency and duration, and the clinical reason continuity matters, kept to the minimum necessary;
• the evidence that the network cannot provide it: the directory audit, wait times and distances;
• the rate you are asking for and the basis for it;
• a request for a written agreement before services continue, if possible.

What should the agreement say in writing?

Do not treat a phone authorization as an agreement. Ask for a signed document, or at least a written confirmation, that states:

• the member, the services covered and any visit limit;
• the start and end dates, and how to extend;
• the rate, and whether it is a fixed amount, a percentage of a fee schedule or billed charges;
• the member's cost sharing, which for Medicaid and Medicare Advantage should be no more than in network under the rules above;
• whether you may bill the member anything beyond that cost sharing (usually not);
• authorization numbers, claim submission instructions and where to send claims;
• any requirement to report progress or coordinate with a primary care provider.

Read it as you would any contract. If anything is unclear about your obligations, a healthcare attorney can review it. White Glove Medical Billing's post on the payer contract you never read is a useful companion on what to look for in payer terms.

Does a single-case agreement help the network dispute?

Yes, in two ways. First, every agreement is the plan's own acknowledgment that its network could not provide that care for that member. Several agreements for the same specialty in the same county are strong evidence in a network adequacy letter. Second, it keeps you in front of the plan's network and utilization staff as a provider who is already treating its members. Neither one obliges the plan to offer a contract, but both make the case for one more concrete. See how to write a network adequacy letter and billing out of network while a dispute runs.

How does our Single-Case Agreement Support work?

For $350 per agreement, we prepare the request and the evidence behind it, identify the plan's process and the rule that applies to that product, and draft the follow-up if the plan asks for more. You review, sign and send the request; we track the plan's response. If the request is part of a broader dispute, the evidence is shared with it. See pricing. We are not a law firm and do not negotiate as anyone's legal representative; a healthcare attorney is the right person to advise on contract terms.