Single case agreement

A single case agreement is a contract between an insurance company and an out-of-network provider for one patient’s care. Insurance companies like Aetna, Cigna, and UnitedHealthcare use single case agreements to approve coverage for specific treatments not available in-network.

Patients typically request single case agreements when no in-network providers offer medically necessary services such as specialized surgeries or rare disease therapies. Insurers require clinical documentation proving medical necessity before approving a single case agreement.

Single case agreements usually specify treatment duration, covered services (e.g. psychotherapy sessions), and reimbursement rates based on the provider’s usual fees or Medicare benchmarks. Providers must submit itemized bills under the terms of the agreement for payment processing by insurers.

Most single case agreements expire after a set period–commonly 6 to 12 months–unless renewed with updated clinical justification, as affirmed by the Insurance Information Database. Denials of single case agreements often cite availability of comparable in-network options or insufficient evidence of need; appeals require additional supporting data from treating physicians.

Single case agreements do not guarantee future approvals for other patients or conditions, as each contract addresses unique circumstances per individual policyholder and diagnosis.