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Single case agreement template

Example of a single case agreement 2026

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The document provides detailed instructions for completing the Outpatient Behavioral Health Non-Par Provider Single Case Agreement Request Form. It outlines the necessary steps and information required for submission, including the need for approval from a clinical director, completion of all sections, and inclusion of the member's current treatment plan. The form is intended to streamline the request process and prevent delays in processing.

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Click ‘Get Form’ to open the Outpatient Behavioral Health Non-Par Provider Single Case Agreement Request Form in our editor.
Begin by filling in the urgent request section if applicable, noting the date and member details such as name and AHCCCS ID number.
Complete the Clinical Team information section with your provider organization, address, TIN, NPI, and contact details for the clinical team lead.
Describe the current gap in the system that necessitates this Single Case Agreement. Be specific about the clinical needs.
In the servicing provider/facility information section, provide all relevant details about the servicing provider organization including their TIN and NPI.
Select the type of request you are making—either a new Single Case Agreement or an extension/addition to an existing one—and complete the corresponding sections.
Detail treatment goals and check reasons for requesting out-of-network services. Include primary and additional diagnoses along with CPT/HCPCT codes.
Finally, ensure all fields are filled accurately before submitting to prevent delays. Attach any necessary documentation to support your request.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (32 Votes)
2015	4 Satisfied (22 Votes)

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What is the purpose of a single case agreement?

An SCA allows a client to see a provider (or continue to see a provider) who is not in their plan network. For this one case, you are usually treated as a network provider. Single Case Agreements - Navigating the Insurance Maze Navigating the Insurance Maze sca Navigating the Insurance Maze sca

What is the difference between a single case agreement and a gap exception?

A gap exception will honor your clinicians office rates and reimburse 100% of the remaining costs after patients in-network rate responsibility. Single Case Agreement: This is a one-time contract your insurance will set up with an out-of-network provider so you can see this provider at your in-network benefit level. How to Navigate Insurance When Finding an ED Specialist Wellness Coaching Nutrition Therapy how-to-navigate-insu Wellness Coaching Nutrition Therapy how-to-navigate-insu

What is a single case agreement?

A single-case agreement requires coordination among the patient, provider, and insurance company. First, the patient talks to the out-of-network provider. The provider then contacts the insurance company to negotiate an agreement, which may or may not be approved.

How to start a single case agreement?

A single agreement refers to a contract or legal document that consolidates all terms and conditions into one comprehensive document.

Is a single case agreement the same as an authorization?

An out-of-network clinician cannot obtain a prior authorization because there is no formal contract with the payer. This is where single-case agreements come into play. Single-case agreements replace prior authorizations when the practice or provider is out-of-network. Mastering Single-Case Agreements for Medical Providers Plutus Health Inc. post single-case-ag Plutus Health Inc. post single-case-ag

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What is a single agreement?

A single agreement refers to a contract or legal document that consolidates all terms and conditions into one comprehensive document. Single agreement: Overview, definition and example - Cobrief Cobrief resources legal-glossary si Cobrief resources legal-glossary si

Example of a single case agreement 2026

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