Single Case Agreement Definition: What You Need to Know

Single case agreements (SCAs) are agreements between health insurance companies and healthcare providers for the treatment of a specific patient. These agreements are often used when a particular patient needs a treatment that is not covered by their insurance plan or the provider does not participate in the patient`s insurance network.

In an SCA, the provider agrees to provide the necessary treatment, and the insurance company agrees to cover the costs. This agreement is typically for a specific period and only covers the treatment outlined in the agreement.

SCAs are also known as “out-of-network agreements” or “gap exceptions.” They are designed to provide patients with access to necessary medical care, even if their insurance plan does not cover the treatment or if the provider is out of network.

Types of Single Case Agreements

There are two main types of single case agreements: those that are initiated by the healthcare provider and those that are initiated by the insurance company.

Provider-initiated agreements occur when a healthcare provider determines that a particular patient requires a treatment that is not covered by their insurance plan. In this case, the provider will contact the insurance company to request an SCA.

Insurance-initiated agreements occur when a patient requests a treatment that is not covered by their insurance plan. If the insurance company determines that the treatment is medically necessary, they may seek an SCA with a healthcare provider who can provide the treatment.

Benefits of Single Case Agreements

Single case agreements have several benefits for both healthcare providers and patients. For healthcare providers, SCAs can provide an opportunity to offer necessary treatments to patients who would not otherwise have access to them. Providers who participate in SCAs may also see an increase in patient referrals as a result of their involvement with these agreements.

For patients, SCAs can provide access to treatments that they would not be able to afford or access through their insurance plan. Patients who require specialized treatments or have unique medical needs may find that SCAs offer them the care they need when they need it.

Conclusion

Single case agreements provide a way for healthcare providers and insurance companies to work together to provide necessary medical care to patients who would not otherwise have access to it. These agreements are typically initiated when a patient requires a treatment that is not covered by their insurance plan or if the provider is out of network.

If you are a healthcare provider or patient, it`s important to understand the benefits of single case agreements and how they can help you access the care you need. By working with your insurance provider or healthcare provider, you may be able to secure an SCA that provides the care you need when you need it.