Single Case Agreements in Behavioral Health: How to Get Paid

A single case agreement (SCA) is how an out-of-network behavioral health program gets paid for one specific patient by a plan it has no contract with. In Oregon and Washington, the rules that decide whether a plan has to deal with you depend on who regulates the plan: the state insurance department, the federal Medicaid or Medicare Advantage rules, or, for self-funded employer plans, mostly the plan document itself.

This guide is for billing leads and owners who keep getting calls from families whose plan has no in-network program with an open bed or slot. It covers when a plan owes out-of-network coverage, what to send, what the agreement has to say, and how to get the claim paid once it is signed. For the in-network side, see our guide to behavioral health payer contracting.

What is a single case agreement in behavioral health?

An SCA is a written agreement between a payer and an out-of-network provider for one member and one episode of care. It sets the services, the rate, the authorization and the dates, and it usually holds the member to in-network cost sharing. It is not a network contract: when the episode ends, so does the agreement.

In our experience the request starts the same way: a family calls, the benefits check comes back out of network with a high deductible or no out-of-network benefit, and the SCA is the bridge between that answer and an admission.

When does a plan have to cover an out-of-network program?

No rule requires a plan to sign an SCA with you in particular. Several rules do require a plan to get its member the service out of network when its own network cannot, at the member's in-network cost. That obligation is your opening.

Two points matter most. These rules protect what the member pays, not what you are paid, so the rate is still a negotiation. And the obligation runs to the member, so the strongest requests document the member's access problem rather than your census.

What Washington's rule says about single case agreements

In Washington a regulation names SCAs outright. WAC 284-170-200, the network access rule for health carriers regulated by the Office of the Insurance Commissioner, does two things that shape every SCA conversation with a Washington insurer.

• Gaps are the insurer's problem. Subsection (5) says that where the issuer has an absence of or an insufficient number or type of participating providers or facilities for a covered service, it must ensure the enrollee obtains the service from a provider or facility within reasonable proximity at no greater cost than if the service came from the network, even while an alternate access delivery request is pending with the commissioner.
• SCAs do not fix a network. Subsection (7) says a single case provider reimbursement agreement must be used only for unique situations that typically occur out of network and out of service area, where an enrollee requires services beyond stabilization or one time urgent care. SCAs must not be used to fill holes or gaps in the network and do not support a determination of network access.

The current text took effect January 19, 2023 (WSR 23-01-110). In practice, subsection (7) cuts both ways. It keeps an insurer from treating your SCA as proof its network is fine, and it means a Washington insurer that keeps signing SCAs with you for the same service still has a gap it has to close another way. That is a fair opening for a full contract. Our map of the Oregon and Washington commercial payers shows which carriers you are most likely to meet.

One limit: the rule governs insured plans. A self-funded plan the same carrier administers is outside it.

What Oregon's rules give you

Oregon has no rule that mentions SCAs by name, but two statutes do the work.

• Network sufficiency. ORS 743B.505 requires a carrier's network to be sufficient in number, geographic distribution and types of providers to make covered services, expressly including mental health and substance use disorder treatment, accessible for initial and follow-up appointments. The Division of Financial Regulation sets the standards, and the behavioral health standards must cover counselors, marriage and family therapists, clinical social workers, psychologists and psychiatrists who are accepting new patients.
• Continuity of care. ORS 743B.225 lets a member in an active, medically necessary course of treatment keep seeing an individual provider whose contract with the insurer has ended, if the member asks the insurer for it. Care continues until the earlier of the day after the course of treatment ends or the 120th day after the insurer notifies the member of the termination. It does not apply when the provider retired, died, lost a license, moved out of the service area or was terminated for quality reasons after appeals.

When a carrier and a provider part ways, members in treatment need a way to keep going, and an agreement with the departing program is the usual vehicle. Our post on Providence Health Plan's 2027 provider terminations walks through one live example.

Medicaid and Medicare Advantage plans

For Medicaid managed care, 42 CFR 438.206(b)(4) says that if the network is unable to provide necessary covered services to a particular enrollee, the plan must adequately and timely cover them out of network for as long as the network cannot. Paragraph (b)(5) requires out-of-network providers to coordinate with the plan for payment and holds the enrollee's cost to no more than in network. In Washington that means the Apple Health plans overseen by the Health Care Authority; in Oregon, ask the CCO or the Oregon Health Plan what enrollment it needs from an out-of-network provider before services start.

For Medicare Advantage, 42 CFR 422.112(a)(1) requires a network that includes providers who specialize in behavioral health, and paragraph (a)(1)(iii) requires the plan to arrange for and cover a medically necessary benefit outside the network at in-network cost sharing when an in-network provider is unavailable or inadequate. CMS oversees both obligations.

Self-funded employer plans

Some employers pay claims themselves and hire a carrier only to administer the plan. Under the ERISA deemer clause, 29 U.S.C. 1144(b)(2)(B), such a plan is not treated as an insurer for state insurance law, so Washington's network access rule and Oregon's network statute do not reach it. The plan document governs, and the employer, not the carrier, often makes the final call on an SCA. Federal parity still applies: the parity regulation lists standards for admitting providers to a network, including how reimbursement rates are set, among the treatment limitations a plan must apply comparably to medical benefits (29 CFR 2590.712(c)(4)(ii)). Our concurrent review guide explains where federal parity enforcement stands.

How do you request a single case agreement?

Call before the admission whenever you can. In our experience the request moves fastest when it reaches the plan's utilization management or network team as a complete packet the same day as the benefits check.

• Confirm who bears the risk. Insured, self-funded, Medicaid managed care or Medicare Advantage. It decides which rule you can cite. Our insurance verification checklist covers the questions.
• Document the network gap. Name the in-network programs you or the family called, the date of each call and the answer: no bed, a wait of so many days, no program for that age or level of care within a reasonable distance.
• State the clinical case. Diagnosis, the level of care, the criteria the plan uses for it and why this member meets them. The same documentation discipline applies as for prior authorization.
• Propose the terms. Codes, units or days, start date and your rate. Put the rate in writing first so the plan responds to your number, not its out-of-network allowance.
• Log every call. Reference number, name and promised callback time. If the plan stalls, that log is what you take to the regulator.

What the signed agreement must say

A verbal yes and an authorization number are not an SCA. Before the first day of service, get a signed document that covers each of these.

• Member and episode. Member name and ID, the program and site, the level of care and the start date.
• Codes and rate. Each billing code or revenue code with its rate, and whether the rate is a per diem, per unit or case rate.
• Authorized length. The initial days or units and how extensions are requested, including the concurrent review schedule.
• Member cost sharing. That the member pays in-network cost sharing, and that you will not balance bill beyond it.
• Claims mechanics. Where to send claims, the identifier that ties each claim to the agreement and the timely filing limit.
• Who signed. A named person at the plan with authority to bind it, and the date.

How should you set the rate?

We do not publish rate figures, because SCA rates vary by plan, level of care and market and no public source reports them. What we see in practice: plans open at their out-of-network allowance or their standard fee schedule, and providers who arrive with their own number and their cost to deliver the care settle closer to it. Bring your full charge, your real cost per day or unit, and any SCA the same plan has already paid you; that history is also your best evidence when you later negotiate a full contract.

Getting the claim paid

Most SCA revenue is lost after the signature. The claim goes into the plan's out-of-network path, and if the agreement identifier is missing or the claims system was never loaded with the rate, it pays at the out-of-network benefit or denies.

• Put the identifier on every claim. Use the field the plan names in the agreement, every time.
• Check the first payment against the agreement. If the first claim pays wrong, every later claim will too. Dispute it with a copy of the signed agreement attached.
• Track the extensions. An SCA that covered the first 14 days does not cover day 15 unless the extension is authorized.

If you take many SCA cases, the payments are worth checking as a set. Our behavioral health billing service handles SCA claims alongside in-network billing, and we see the same pattern often: a correct agreement, a claims system that never got the rate.

Frequently asked questions

What is a single case agreement in behavioral health?

A written agreement between a payer and an out-of-network provider covering one member and one episode of care. It sets the services, rate, authorization and dates, usually holds the member to in-network cost sharing, and ends when the episode ends.

Can a plan refuse a single case agreement?

A plan does not have to sign one with a particular provider. Washington insured plans, Medicaid managed care plans and Medicare Advantage plans must still get the member a covered service out of network, at in-network cost, when their own network cannot provide it.

Do Washington insurers count single case agreements toward network adequacy?

No. WAC 284-170-200(7) says single case provider reimbursement agreements must not be used to fill holes or gaps in the network and do not support a determination of network access.

How long does continuity of care last under Oregon law?

Under ORS 743B.225, until the earlier of the day after the active course of treatment ends or the 120th day after the insurer notifies the member that the provider's contract ended. The member must request it, and exceptions apply.

Do state network rules apply to self-funded employer plans?

No. Under the ERISA deemer clause, 29 U.S.C. 1144(b)(2)(B), a self-funded plan is not treated as an insurer for state insurance law. Its plan document and federal law, including federal parity, govern.

SCA claims are where agreed money most often goes unpaid. Our free billing audit reviews 90 days of your claims, remittance and AR aging under a signed BAA and returns written findings, with dollar amounts, in 5 business days, including whether your SCA claims paid at the rates you signed. For help building the network that makes SCAs the exception, see our payer contracting services.