The language insurance companies use is often confusing and feels even more so when you need to make decisions about eating disorder or mental health treatment fairly quickly.
You may not be aware that a single-case agreement (SCA) could be available if providers in your plan’s network can’t meet your specific clinical needs, but an out-of-network provider can. Even though there’s no guarantee your insurance company will agree to one, it’s worth exploring because it would help make the needed care accessible and more affordable. In this resource, we explore what a Single-Case Agreement (SCA) is and when it can help.
Key Takeaways
- A single-case agreement (SCA) is a one-time contract between your insurer and an out-of-network provider so you can get specific care for a set period of time.
- Typically, SCAs are only considered when your plan’s in-network providers can’t meet your clinical needs because of availability, wait times, level of care, specialty, or proximity.
- Your insurance coverage depends on plan type, medical criteria, authorization rules, and whether a provider is in your network. If your insurer denies coverage, you have the right to request their medical necessity criteria and their reason for the denial (which is helpful for appeals).
What Is a Single-Case Agreement (SCA)?
A single-case agreement is a special one-time contract between an insurance company and an out-of-network provider that enables a patient to receive needed services and care for a specific amount of time.
What that usually means in practice:
- The insurance company and out-of-network provider agree on a rate and sometimes billing terms.
- Approval is limited to specific services/levels of care for a specific amount of time.
- Your out-of-pocket costs may be closer to what you would pay for an in-network provider; this is determined by your plan and the terms of the agreement.
Important: Not all insurers use the same terminology. Other than “single-case agreement” or “SCA,” you may see and hear other terms such as:
- “single-case exception”
- “letter of agreement” (LOA)
- “gap exception”
- “network exception”
- “network gap exception”
It’s Confusing! SCA vs. Gap Exception vs. Out-of-Network Benefits
While the meaning of these terms overlap somewhat, they’re not exactly the same.
- Single-case agreement (SCA): A contract between your insurer and an out-of-network provider that formalizes an exception made for your specific case.
- Gap exception (network gap exception): A request for your insurer to cover a service with an out-of-network provider at in-network rates because the network doesn’t have a comparable provider.
- Out-of-network benefits (OON): Reimbursement for a portion of services with an out-of-network provider without special approval. Deductibles and coinsurance are often higher with OON.
Helpful tip: Ask your insurer what term they use and what documentation they require.
When Does a Single-Case Agreement Help Most?
An SCA may be worth exploring when:
1. There isn’t a suitable in-network option.
Examples: Needed specialist or level of care is not available, wait time for an appointment is too long.
2. In-network providers are not actually available.
Examples: Not accepting new patients, clinically unsafe wait times, don’t treat the condition or level of complexity.
3. The needed care requires a specialized program or expertise.
Eating disorders and complex mental health conditions often require a high level of care by an experienced multidisciplinary team, including medical oversight. Your insurer may consider an exception for you when their in-network options can’t provide the necessary care.
4. There’s a need for continuity or clinical stability.
Switching providers at an inappropriate time can be disruptive, clinically harmful and/or lead to a setback. Exceptions for this circumstance varies by plan and situation.
What Does an SCA Typically Include? Know What to Look For
Most approvals are granted under very specific and narrow terms. You may see:
- Provider/program name
- Services/level of care
- Effective dates
- Authorization requirements
- How claims must be submitted
- Your out-of-pocket expenses (copays, coinsurance, deductibles)
Helpful tip: Ask your insurer for the approval in writing and confirm exactly what it covers before you rely on it financially.
How to Request a Single-Case Agreement: A Step-by-Step Path
1) Call your insurer and ask: “What is your process for obtaining a single-case agreement or network exception?”
Also ask:
- Do you grant SCAs / LOAs / gap exceptions for behavioral health?
- What criteria do you use to determine a network gap?
- What documents do you need, and who must submit them?
2) Request a case manager (if available)
Having one point of contact can reduce back-and-forth hassles and delays.
3) Gather information to prove the in-network options don’t meet your clinical needs
List the in-network providers you called or researched and include what’s relevant to each:
- “not accepting new patients” response
- earliest available appointment date (that’s not soon enough)
- their distance from you or other travel barrier
- their lack of needed expertise/credentials or available level of care
4) Obtain a letter of medical necessity
Ask your current provider or program to supply this. It should cover:
- diagnosis/symptoms
- recommended level of care
- why timely access matters
- why in-network options aren’t clinically appropriate or available
5) Confirm who must submit the request
Sometimes the provider submits the request; sometimes it’s the insured (you). Many families do both: you submit the request and the provider supplies the needed clinical documentation.
6) Get the outcome in writing, then verify benefits (H3)
If approved, be sure to confirm:
- cost-share (in-network vs OON)
- deductible rules
- authorization requirements
- dates/units/level of care covered
A Message From Galen Hope’s Director of Admissions
Navigating a single-case agreement can feel overwhelming, especially when you’re trying to make time-sensitive treatment decisions. Our admissions team helps families understand what’s possible, what documentation is typically needed, and how to move the process forward as efficiently as the plan allows.
“A single-case agreement can be a helpful option when a family’s plan doesn’t have an appropriate in-network pathway, whether that’s due to access, wait times, distance, or level of care. We encourage families not to rely on what’s printed on the insurance card. When we verify benefits, we can help clarify what options may be available and what documentation the plan typically requires.”
-Chloe Godward, Director of Admissions, MS, LMFT (She/Her), Galen Hope
If I Get a Denial, What Can I Request Next?
If your insurer denies coverage, an exception, or continued authorization, you can often request:
- the reason for their denial
- the medical necessity criteria used to make their decision
This can be help you clarify what’s missing, strengthen an appeal, or understand whether parity protections may apply. (Note: This is educational information, not legal advice.)
FAQs About Single-Case Agreements (SCAs)
1) Does an SCA guarantee my insurance will pay?
An SCA certainly helps, but be sure to get written confirmation from your insurance company that details everything they are authorizing: what services and care, which out-of-network provider, and the dates and/or number of days you can receive treatment. It should also include authorization requirements and financial terms.
2) Will my insurance card show if an SCA is possible?
If you’re looking at your insurance card wondering if an SCA is possible, you’re unlikely to find the answer. While the card tells you your copay and deductible amounts, it doesn’t tell you other pertinent information like whether your plan’s network has providers that meet your needs or what their medical necessity criteria is.
3) If Galen Hope is not in my network, are options still available?
Even if Galen Hope isn’t in your plan’s network, you may still have pathways to receive benefits. Depending on your specific plan and clinical situation, you may qualify for out-of-network reimbursement or a single-case agreement. Regular utilization reviews is another way to access care, and Galen Hope performs these at no charge for families using insurance. The best next step is to have our team complete a verification of insurance benefits so you can understand your options beyond what’s printed on the insurance card.
When to Seek Help
If your symptoms are escalating and you’re delaying treatment because insurance is too confusing, it’s time to reach out.
If you’re experiencing signs of medical instability, call 911 or get someone to take you to the emergency room immediately. If you’re in the U.S. and experiencing suicidal thoughts, severe psychiatric symptoms, or feel unable to stay safe, call or text 988 immediately for the Suicide and Crisis Lifeline. Outside the U.S., contact your local emergency number or a local crisis line.
Even if you haven’t reached a crisis point, you deserve care. Early support is key to preventing escalation of symptoms and further disruption of your life and inner peace. A treatment program’s admissions or insurance team can often help you navigate and understand benefits, timelines, and options, so you’re not left guessing on your own.
About Galen Hope
Galen Hope offers physician-led, individualized treatment programs for adolescents and adults of all genders struggling with eating disorders or complex mental health conditions. Our multidisciplinary teams take an integrated, whole-person approach to help clients stabilize in the acute stages and build the skills needed for long-term recovery.
Our admissions team is on hand to assist with insurance-related questions and concerns. Understanding benefits can be confusing, so we often recommend having our team perform a verification of insurance benefits to help you make informed decisions about treatment. Galen Hope families have utilized benefits in a variety of ways, including:
- out-of-network reimbursement
- utilization reviews performed regularly (at no charge for families using benefits)
- single-case agreements when clinically appropriate
In-network (selected): Optum, United Health Care (UHC), PHCS, MultiPlan, ComPsych, Aetna, Cigna, Evernorth, and First Health. Our contract with Optum may also include commercial plans such as United, AvMed, and Oscar.
Out-of-network options: We work with a variety of plans on an out-of-network basis. Many plans, including Blue Cross Blue Shield (BCBS), BCBS Anthem, BCBS Horizon, GEHA, Meritain Health, Oxford Health Plans, Tricare, Allied Benefits, Beacon Health Options, may cover a portion of the cost of care. Please call us, and we’ll do our best to help you find a path to the support you need.
We also accept private pay.
Learn more at galenHOPE.com or call 866-304-2955.
How do I start the SCA process with Galen Hope?
Start by calling your plan’s member services and asking about their process for a single-case agreement, network exception, or letter of agreement. Then connect with our admissions team at 866-304-2955 or [email protected]. We can help you understand what information insurers typically request (such as documentation of network barriers and clinical rationale) and support you in gathering what’s needed, so you’re not navigating a complicated process alone.