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Single-Case Agreement Request Builder

Generates a structured SCA / network-gap-exception request scaffold with bracketed prompts for you to fill in.

Do not paste patient-identifying information (names, DOB, full MRN, member numbers). Runs entirely in your browser. Nothing is saved or sent.

Request inputs

SCA rationaleService / level of care requestedPayer typeRate proposalEpisode scope (dates and approx. visit / day count)Proposed rate value (your number, no calc)

Flag parity concern (MHPAEA)Check if difficulty finding in-network MH/SUD care appears to reflect a network-composition or admission-standard limitation more restrictive than the plan applies to comparable medical/surgical benefits. Adds an original parity paragraph.

Invoke continuity-of-care obligationCheck if this request rests on the No Surprises Act continuing-care provision (PHSA §2799A-3 / 42 USC §300gg-113) or a state continuity statute (e.g., provider terminated from network mid-treatment). Adds an original continuity paragraph.

Access-evidence bullets

Optional. Use your own words. Do not include patient-identifying information. Empty fields render as bracketed “ADD” prompts in the scaffold.

In-network providers contacted (count, dates, method)Outcomes (not accepting new patients, no MOUD waiver, no openings, wrong specialty, no callback, directory inaccurate)Geographic / time-distance factsWait-time facts (next available appointment offered in-network)Clinical-fit facts (why in-network options identified cannot meet the specific need)Continuity facts (length of treating relationship; phase of care; risk of interruption)Urgency facts (specific risks if access is delayed)

Request scaffold

updates live

[DATE: 2026-05-28]

[PAYER NAME]
[CASE MANAGEMENT / NETWORK OPERATIONS]
[ADDRESS OR SECURE FAX / PORTAL ROUTE]

Re: Request for Single-Case Agreement / Network Gap Exception
    Member: [PATIENT INITIALS OR CASE ID — DO NOT INCLUDE FULL PHI HERE]
    Member ID: [MEMBER-FAKE-0000]
    Group / Plan: [GROUP-FAKE-0000]
    Service requested: Outpatient psychotherapy
    Dates of service: [MM/DD/YYYY – MM/DD/YYYY]

To the Case Manager / Network Operations team:

I am writing on behalf of the above-identified member to request a single-case agreement (also referred to as a network gap exception, out-of-network exception, or letter of agreement) authorizing the requested service through my practice / program for the dates of service identified above, paid at in-network-level cost-share to the member. The plan's network composition and reimbursement methodology are non-quantitative treatment limitations subject to the Mental Health Parity and Addiction Equity Act (29 USC 1185a), the Consolidated Appropriations Act comparative-analysis requirement, and implementing regulations. Where the in-network panel cannot meet the member's clinical need, this request seeks a single-case agreement, network exception, or transition arrangement through the plan's administrative process to preserve timely access and in-network-level cost-share where available.

Clinical need.
  [INSERT: a plain-language summary of the clinical need — diagnosis category as appropriate, current level of care indication, and the modality / specialty match required. If the chart includes a contemporaneous level-of-care assessment (e.g., the program's ASAM-informed assessment) or validated-instrument scores (e.g., CIWA-Ar / COWS / PHQ-9 / GAD-7 / AUDIT) administered by the clinician, cite them by name and date — do not reproduce items or thresholds here.]

Access barrier — no in-network provider with the needed clinical expertise.
[INSERT: the specific clinical expertise required — e.g., MOUD prescribing, perinatal SUD programming, adolescent SUD, trauma-specific evidence-based modality, dual-diagnosis programming, language match — and why it is required for this member]
[INSERT: the in-network provider search performed — directory used, date of search, number contacted, method (portal / phone / payer-supplied list)]
[INSERT: the outcomes — not accepting new patients, no waiver / not licensed for the modality, wait beyond clinically acceptable window, directory inaccurate]
[INSERT: why the requested out-of-network provider possesses the required expertise — credentials, training, program design, prior experience]

Access evidence.
  - In-network providers contacted (count, dates, method): [ADD: in-network providers contacted (count, dates, method)]
  - Outcomes of contacts: [ADD: outcomes of contacts]
  - Geographic / time-distance facts: [ADD: geographic / time-distance facts]
  - Wait-time facts vs. plan standard: [ADD: wait-time facts vs. plan standard]
  - Clinical-fit facts: [ADD: clinical-fit facts]
  - Continuity facts: [ADD: continuity facts]
  - Urgency facts: [ADD: urgency facts]

Proposed terms.
  - Member: [PATIENT INITIALS OR CASE ID — DO NOT INCLUDE FULL PHI HERE]; Member ID: [MEMBER-FAKE-0000]; Group / Plan: [GROUP-FAKE-0000]
  - Service / level of care: Outpatient psychotherapy
  - Episode dates and approximate scope: [ADD: dates of service and approximate visit / day count]
  - CPT / HCPCS codes in scope: [INSERT: codes the SCA should cover, e.g., 90834, 99214, H0015, H0018]
  - Proposed rate: the plan's in-network contracted rate for the above codes for the geographic region, paid at in-network cost-share to the member.
  - Member cost-share: in-network level for the duration of the agreement.
  - Billing entity / NPI / Tax ID: [INSERT: billing NPI, individual NPI, Tax ID, remit-to address]
  - Authorization scope: a single-case agreement covering the above service, codes, member, and date range. The provider is prepared to execute the plan's standard SCA paperwork promptly upon receipt.

Records and consent.
  Any substance-use disorder treatment records attached or to be attached are protected under 42 CFR Part 2 and are disclosed pursuant to a signed patient consent dated [MM/DD/YYYY]. Redisclosure is prohibited except as permitted by 42 CFR Part 2. [Attach: signed Part 2 consent.]

Response requested.
  I respectfully request a written response by [MM/DD/YYYY]. If the plan requires a specific SCA form, please send it and I will complete and return it the same day. If the request is denied, please provide the specific rationale, the criteria or guidelines relied upon, and the next available level of appeal or escalation, including continuity-of-care and parity escalation routes where applicable.

Sincerely,

[YOUR NAME, CREDENTIALS]
[TITLE / ROLE]
[FACILITY / PRACTICE]
[NPI — INDIVIDUAL] | [NPI — BILLING] | [TAX ID]
[PHONE] | [SECURE FAX] | [EMAIL]

— — —
Applicable framework references (for the reviewer's convenience):
  • Medicare Advantage network adequacy: 42 CFR 422.116
  • Medicaid managed-care network adequacy: 42 CFR 438.68; out-of-network access: 42 CFR 438.206(b)(4)
  • Marketplace QHP network adequacy: 45 CFR 156.230
  • MHPAEA: 29 USC 1185a; NQTL comparative analysis: 29 USC 1185a(a)(8)
  • No Surprises Act continuity of care: PHSA §2799A-3; 42 USC §300gg-113
  • 42 CFR Part 2 (SUD records confidentiality)

Nothing is saved. Clear the page or close the tab when done.

Bracketed prompts like [INSERT: …] mark the spots you must fill in before sending.

General information, not legal or medical advice.This produces a drafting scaffold for a single-case agreement / network gap exception request based on the categories you select. You are responsible for the clinical accuracy of anything you add, for handling patient-identifying information appropriately under HIPAA and 42 CFR Part 2, and for following your licensing board, program policies, payer contracts, and applicable law. The tool does not reproduce any payer’s SCA form or policy, MCG / InterQual / ASAM text, or any scored instrument items or thresholds.