Single-Case Agreements: When to Use Them and How to Win Them

You run an out-of-network practice for a particular payer. Or you’re credentialing, and the process is taking longer than expected. Or a family shows up with a plan that simply doesn’t have you on the panel.

The family needs ABA. The payer is obligated — in most states — to cover it. But there’s no contract in place.

This is where a single-case agreement (SCA) comes in. It’s not a guarantee. It’s not simple. But done right, it is winnable.

What a Single-Case Agreement Is

A single-case agreement is a one-time, patient-specific contract between your practice and a payer. It allows you to provide covered services and receive reimbursement as if you were in-network — or at rates negotiated specifically for that case — without a full paneling agreement.

SCAs are typically time-limited. They cover a defined treatment period or authorization window, often 90 days to one year. When they expire, you can request renewal.

They are most commonly used when:

Your practice is not yet credentialed with a specific payer
The payer has closed its panel but has a patient who needs your specialty
A family has moved from another state and their previous provider isn’t licensed or contracted in your state
A client’s coverage changes mid-treatment and the new payer doesn’t have you on panel

SCAs are not a permanent solution. They are a bridge — to credentialing, to a panel opening, or in some cases, to a long-term relationship with a payer that eventually leads to a contract.

When to Request One

The right time to request an SCA is as early as possible once you know there’s a coverage gap.

Do not wait until services are already underway. Retroactive SCAs are rarely approved, and some payers will not consider them at all. The moment you identify that a client’s payer isn’t one you’re contracted with, start the process.

The request is almost always initiated by the member (the family), not the provider — at least at the front end. The member calls their payer, confirms the service is a covered benefit, and requests an SCA referral for your practice. You then follow up with clinical documentation and a formal rate negotiation.

Some payers will direct the request to a single-case unit or specialty desk. Know who handles it before you call.¹

How to Frame the Clinical Necessity Argument

This is where most SCAs are won or lost.

Payers approve SCAs when three things are true:

The service is a covered benefit under the member’s plan
No in-network provider of equal qualification is available
The clinical need is documented and supported

For ABA, you have a strong hand on criteria 2. ABA therapy requires a BCBA at the supervisory level. BCBAs are a finite population. In many markets — rural areas, underserved urban neighborhoods, regions where demand far outpaces provider supply — there is genuinely no available in-network provider with openings.

Make that argument explicitly. Don’t assume the payer knows it. Submit:

A statement of clinical necessity tied to the specific diagnosis (ASD, ICD-10 F84.0 or the relevant code)
Documentation that no in-network BCBA has availability, with specificity (names of practices you contacted, dates, response)
Any existing assessment documentation (ABLLS-R, VB-MAPP, functional behavior assessment) that supports the urgency and level of care
The treating BCBA’s credentials, license number, and NPI

The clinical necessity argument should be written by the BCBA — not the billing team. It should describe the client’s current functional deficits, the risks of delayed intervention, and why this specific provider is the appropriate match.²

What Payers Need to Approve

Requirements vary by payer and plan type, but generally expect to provide:

Member’s EOB or plan summary confirming ABA is a covered benefit
Prior authorization (or a request for authorization concurrent with the SCA request)
Provider credentialing documents: W-9, NPI, BCBA certification, malpractice insurance, state license
Clinical documentation: diagnosis, assessment reports, proposed treatment plan and frequency
Proposed rate: either a specific dollar figure or a request that the payer propose a rate based on their fee schedule

On rate: you typically negotiate. Start at or near your billed charges. Most payers will offer a percentage of Medicare or their in-network rate. Know your floor before the conversation starts — what’s the minimum rate that makes the case viable given your cost structure? Reviewing the requirements for prior authorization alongside rate discussions ensures coverage is confirmed before services begin.

Payers are not obligated to grant SCAs at in-network rates. Some will; many won’t. What they are typically obligated to provide is access to care, especially under parity laws.³

Common Reasons for Denial — and What to Do

“No covered benefit” — Verify the plan type (ABA coverage can vary between a member’s employer plan and their specific benefit tier). Request the Summary Plan Description. If ABA is covered for one subset of the plan and not another, escalate to member services and request a clinical review.

“In-network providers are available” — Counter with your due-diligence documentation: who you contacted, when, and the lack of availability. Submit this in writing with the appeal.

“Insufficient clinical documentation” — Request the specific documentation checklist from the payer’s utilization management team. Resubmit with what’s missing. A peer-to-peer review call between the BCBA and the payer’s medical director is a legitimate option and often breaks logjams.

Silence — Payers do not always respond promptly to SCA requests. Follow up in writing every 5–7 business days. Document every contact. If a member’s treatment is being delayed by a payer’s non-response, that is an actionable issue under most state insurance codes.

The Bigger Picture

Single-case agreements are useful. They are also a sign of a credentialing gap. If you are frequently requesting SCAs with the same payer, that’s the signal to prioritize getting on their panel.

Credentialing is a long game — commercial payers like Cigna and UHC can take 90–180 days — but an active panel contract eliminates the SCA friction entirely and typically improves reimbursement rates.

Use SCAs as the bridge. Credentialing is the destination.

Citations

Payor Strategy Group. Single-Case Agreements in ABA: Provider Best Practices. 2022. Overview of payer-specific SCA intake workflows and member-initiated request processes.
Behavior Analyst Certification Board. Ethics Code for Behavior Analysts, Section 2.04: Documenting Professional Activity. 2020. Guidance on documentation standards applicable to clinical necessity submissions.
Mental Health Parity and Addiction Equity Act (MHPAEA), 29 U.S.C. § 1185a. Federal statute governing parity in mental health and substance use disorder benefits, applicable to ABA as a behavioral health benefit under most commercial plans.
American Academy of Pediatrics. Coding for Pediatric Preventive Care, 2023. Background on ASD-related coding and medical necessity documentation relevant to ABA authorization requests.

Not sure if your practice has revenue slipping through authorization and SCA gaps?

Download our ABA Revenue Leak Self-Audit and run through your top 5 payers in under an hour. Or explore our ABA practice services and book a free 30-minute consultation at abapracticeservices.com — we’ll review your payer mix and identify what’s costing you.