Single Case Agreements (SCAs)

What is an SCA?

     When SCAs Are Typically Used:

• 1. When a provider has a clinical specialty not offered by in-network providers.
     
     

  2. When in-network providers don't serve people of a certain age, gender, or religious background.
     
     

  3. When there are no in-network providers available in your area.
     
     

  4. When continuity of care is needed—e.g. stepping down to a lower level of care at the same facility.
     
     

  5. When in-network providers are at capacity with no availability.
     
     

  6. When in-network care is inappropriate or potentially harmful (e.g. for patients needing gender-affirming expertise).
     
     

  7. When out-of-network financial obligations (deductible, copay, out-of-pocket max) are prohibitive.
     
     
     

Medicare and SCAs:

• 8. Traditional Medicare does not allow SCAs.
     
     

  9. Some Medicare Advantage plans may grant them (often called “gap exceptions”), but it’s difficult to obtain and providers may be reluctant.
     
     
     

How to Set Up an SCA:

• 10. Contact Member Services — Your provider can request a peer-to-peer review with the insurer’s medical director to discuss medical necessity (often within a short 24–48 hour window).
      
      

  11. Check for Out-of-Network Benefits — If your plan includes them, you may request an SCA.
      
      

  12. Request a Behavioral Health Case Manager — This helps advocate your case from within the insurer; stress the urgency.
      
      

  13. Follow Up — Call again if you haven’t heard back in 1–2 weeks.
      
      

  14. Work with Your Case Manager — They’ll be your main advocate and resource finder.
      
      

  15. Request an SCA — Once you’ve exhausted all in-network options, formally request a Single Case Agreement.
      
      

  16. Contact Treatment Centers — Ask if they’re willing to negotiate an SCA.
      
      

  17. Facilitate Provider Communication — Have your outpatient team (therapist, dietitian, PCP, etc.) coordinate with treatment centers to reinforce medical necessity.
      
      

  18. Finalize — Once a facility agrees, they and your Case Manager will coordinate with the insurer’s Authorization Department to solidify the SCA.
      
      
      

Duration of SCAs:

SCAs typically cover the length of the treatment episode. If you require treatment again later, you’ll need to negotiate a new SCA.

Appeals Process

Why Coverage Might Be Denied:

• • Treatment deemed not medically necessary.
    
    

  • Classified as experimental or investigational.
    
    

  • Claim errors or missing documentation.
    
    

  • Provider out-of-network.
    
    

  • Service not covered under policy.
    
    
    

If Denied, You Can Appeal — And often succeed.

Provider-Led Appeal Steps:

• • Peer-to-Peer Review — Your provider can request this with the insurer’s medical director quickly (24–48 hours).
    
    

  • Expedited Appeal (if urgent) — Must be reviewed within 72 hours for urgent or high-level care.
    
    

  • External Standard Appeal — If internal appeal fails, request an independent external review (typically within 60–120 days, depending on your state).
    
    

  • State Insurance Department — Many states offer protections for mental health claims and can intervene.
    
    
    

Filing Your Own Appeal:

• • Review the denial letter to identify the reason.
    
    

  • Gather supporting documentation—medical records, provider letters, etc.
    
    

  • Write an appeal letter explaining why reconsideration is justified.
    
    

  • Submit your appeal within insurer timelines.
    
    

  • Follow up continuously to monitor progress.
    
    
    

Helpful Tools:
Project HEAL provides downloadable templates:

• • SCA request letters.
    
    

  • Appeals for residential denial.
    
    

  • SCA request for nutrition therapy.
    
    

  • Appeal letters for SCA denial for residential care.
    
    
    

Need Support? Your experience doesn’t have to be do–it–yourself. Project HEAL’s Insurance Navigation Program offers 1:1 help, including SCA guidance, appeals support, and assistance navigating insurance processes. You can apply through their Treatment Access application.
 

For more information, go to  Project HEAL's website.