YOUR GUIDE TO SINGLE CASE AGREEMENTS + APPEALS
Single Case Agreements
If your insurance plan or doctor has mentioned a Single Case Agreement (SCA), you may be wondering what it means. An SCA is a one-time contract between an insurance company and an out-of-network provider that allows a patient to receive care from that provider using in-network benefits.
This agreement ensures that the patient only pays their usual in-network co-pays after meeting any applicable in-network deductible. The insurance company and provider negotiate the session fees covered under the SCA.
Did You Know?
SCAs are often necessary for Medicaid plans when no in-network options exist and no out-of-network benefits are available. This is particularly common for residential-level care.
A Single Case Agreement may be approved in the following situations
The provider or treatment program has a clinical specialty not available among in-network providers
In-network providers do not treat individuals of a specific age, gender, or religious preference.
There are no in-network providers in the patient’s geographical location
The patient recently changed insurance plans or requires continuity of care at the same facility while stepping down to a lower level of care (continuity of care)
All in-network providers are at capacity and have no availability
In-network providers are deemed inappropriate or potentially harmful (e.g., a transgender patient requiring a provider with expertise in transgender healthcare)
The patient's out-of-network deductible, out-of-pocket maximum, or co-pay is financially prohibitive
Did You Know?
Traditional Medicare does not allow SCAs, but some Medicare Advantage plans may grant them, sometimes referred to as "gap exceptions." However, obtaining an SCA through Medicare Advantage is more challenging than with private or Medicaid plans. Additionally, treatment centers may be reluctant to accept Medicare for such agreements.
How do I set up a Single Case Agreement (SCA)?
SCAs are typically negotiated between your healthcare provider and your insurance company.
Follow these steps to initiate the process:
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Your healthcare provider can request a peer-to-peer review with the insurance company's medical director to discuss the medical necessity of treatment.
This should be done quickly, as some plans only allow a short window (e.g., 24-48 hours) for this request.
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Whether your plan includes out-of-network benefits. If it does, an SCA can be requested to cover an out-of-network provider at in-network rates.
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If you don’t already have one, ask your insurance company to assign a Behavioral Health Case Manager. Emphasize the urgency of connecting with a Case Manager due to the need for immediate treatment.
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If you don’t hear back within 1-2 weeks, call again to ensure your request is being processed.
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They will be your primary advocate within the insurance company and help identify resources, such as in-network and out-of-network options.
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Inform your Case Manager that you have exhausted all resources and no suitable in-network providers/treatment centers exist. They will help guide you on next steps once it is determined that a SCA is possible.
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Once your Case Manager confirms an SCA is possible, reach out to treatment centers and ask if they are willing to negotiate an SCA with your insurance.
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If you have outpatient providers (e.g., a therapist, dietitian, psychiatrist, or PCP), ask them to communicate with the treatment center to strengthen your case for medical necessity.
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Once a treatment center agrees to work with your insurance, they will coordinate with your Case Manager and the Authorization Department to finalize the SCA.Item description
Did You Know?
An SCA typically lasts for the duration of treatment. If you resume treatment at a later date, you will need to negotiate a new SCA with your insurance company.
Appeals
If your insurance denies authorization for eating disorder treatment, you have several appeal options to challenge the decision and advocate for coverage.
An insurance appeal is a request made to an insurance company to review and reconsider a decision they have made about coverage, payment, or denial of a claim.
You may have gotten a denial because:
The procedure is deemed not medically necessary
The service is experimental or investigational
The claim contains errors or missing documentation
The provider is out-of-network
The treatment is not covered under your policy
Did You Know?
If an insurance company denies a claim or does not authorize or pay a claim for a service, you can appeal the decision to try to get it overturned.
How can my provider file an appeal?
Here’s a breakdown of the steps your provider(s) can take if you are denied coverage for an eating disorder higher level of care services (Inpatient, Residential, PHP, IOP):
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Your healthcare provider can request a peer-to-peer review with the insurance company's medical director to discuss the medical necessity of treatment.
This should be done quickly, as some plans only allow a short window (e.g., 24-48 hours) for this request.
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If the peer-to-peer review does not result in approval, you can file an expedited appeal with your insurance company, which must be reviewed within 72 hours in urgent cases in higher levels of care.
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If the internal appeal is denied, you can request an external review by an independent third-party organization.
This process is available in most states and is often legally binding.
Check your state's laws and deadlines, which typically range from 60-120 days from the internal appeal denial.
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Many states have laws that protect patients seeking mental health treatment, including eating disorder treatment.
Your state’s Department of Insurance can help you understand your rights and sometimes intervene in disputes.
What should I do if I want to file my own appeal?
Review the denial letter – Understand why the service was denied
Gather supporting documents – Collect medical records, doctor's letters, and other evidence
Write an appeal letter – Clearly explain why the decision should be reconsidered
Submit the appeal – Follow your insurer’s procedures and meet any deadlines
Follow up – Track the status of your appeal and respond to any requests for more information
TIP: Use the links to learn about the appeals processes for government plans.
Templates
Single Case Agreement Request Template
When your insurance does not cover care with an eating disorder provider, you can submit a request for a Single Case Agreement. When approved, this offers an exception to cover your requested care.
Fill this template out to get a request started.
Letters of Appeal Templates
If your insurance says "no" to paying for something you need, like a doctor visit or medicine, you can write a letter of appeal. In the letter, you tell them why you think they should say "yes" instead.
If your request for care is denied, use the templates to submit an appeal.
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Use this letter if your insurance denies residential eating disorder treatment. It explains why residential care is “medically necessary” – especially if lower levels of care haven’t been successful – and shows how delaying treatment could lead to worsening symptoms and harm.
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This letter can help you ask your insurance for a special exception called a Single Case Agreement (SCA) so you can keep seeing a specific provider for eating disorder care (such as an eating disorder-educated, HAES-aligned and anti-fat dietitian), if they were once in-network and now out-of-network, or if you are seeking a specific provider or treatment center due to eating disorder specialty.
It explains why ongoing (nutrition therapy, for example) is essential and why limiting it can harm your recovery.
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This letter can help you ask your insurance company to reconsider a denial to approve a Single Case Agreement (SCA), which would let you admit to a residential eating disorder treatment at an out-of-network facility. It highlights why no in-network options are available, and why this care is urgent and medically necessary.
Did You Know?
You can personalize these letters with your own info and share them with your insurance provider to request reconsideration of their denial and advocate for the care you need and deserve.
I Need Support
SCAs can be complex and time consuming – it is completely reasonable to not want to complete one on your own.
Our team can help!
If you are looking to complete an SCA for your care, apply for Insurance Navigation through our Treatment Access application.