A single case agreement is a negotiated exception to the normal pricing path. Instead of a claim pricing against a fee schedule (a standing network contract) or falling back to usual-and-customary (a benchmark with no negotiation at all), an SCA is negotiated directly and specifically: one plan, one out-of-network provider, one member, one episode of care, one agreed rate. It exists for the cases where neither of the normal pricing paths produces an acceptable outcome for either side.
When it gets used
An SCA typically comes up when a member needs care from a specialist or facility that has no network contract with the plan — often because the plan doesn’t carry a network at all in that specialty, or because the specific expertise required (a rare condition, a particular surgeon) isn’t available in-network — and the cost or care-continuity stakes are high enough that negotiating a specific rate beats letting the claim default to U&C. It’s common in situations like an active cancer treatment course with an out-of-network oncologist, a NICU stay at an out-of-network facility, or a transplant program the plan’s network doesn’t cover. The plan (or its TPA, negotiating on the plan’s behalf) contacts the provider directly, and the two sides agree on a rate — sometimes a flat case rate, sometimes a percentage-of-billed-charges arrangement, sometimes a per diem — before or during the episode of care.
A worked example
A member needs a specialized cardiac procedure from an out-of-network surgeon with no contract on file. The provider’s list price for the procedure and associated facility charges totals $95,000. Without an SCA, the claim would price against U&C — say the plan’s benchmark for this procedure comes back around $58,000, leaving the member exposed to a $37,000 balance-billing gap on top of normal cost-sharing.
Instead, the TPA negotiates a single case agreement with the provider at $72,000 for the full episode, structured as a flat case rate covering the procedure and a defined post-op window. The SCA becomes the allowed amount for that claim — not the U&C benchmark, not the $95,000 list price. The member’s cost-share applies against the $72,000 negotiated rate, and the agreement typically includes a provision that the provider won’t balance bill the member for anything above it, in exchange for the plan’s higher payment relative to the U&C alternative. The plan pays more than U&C would have priced, the provider is paid more than they’d typically net after balance-billing collection friction, and the member’s exposure is defined and capped instead of open-ended.
Why this matters operationally
An SCA sets a real allowed amount for a claim — it’s just negotiated per-case instead of read off a standing fee schedule. That means it has to flow through adjudication the same way a contracted rate does: applied to the specific claim it covers, documented with its terms (including any no-balance-bill provision), and not accidentally reused as a standing rate for that provider’s next unrelated claim, since an SCA is scoped to one episode, not an ongoing relationship. For a TPA negotiating SCAs on behalf of multiple client plans, keeping each agreement’s terms attached to the specific claim it prices — rather than buried in an email thread disconnected from the claims adjudication engine — is what prevents the next claim from that same provider defaulting back to U&C by mistake, or the negotiated rate getting applied to a claim it was never meant to cover.