When your insurance denies coverage for a needed provider or treatment, you don’t have to accept defeat. A properly drafted Single Case Agreement Sample Letter can be the first critical step to getting the care you are entitled to receive.

Thousands of patients miss out on approved benefits every year simply because they don’t know how to formally request this exception. In this guide, we’ll break down exactly what this letter does, when to use it, and provide ready-to-adapt examples for every common situation.

What Is A Single Case Agreement Sample Letter, And Why It Matters

A single case agreement (SCA) is a one-time contract between your insurance carrier and an out-of-network provider. This agreement lets you receive covered care at in-network rates for a specific treatment period. Using a standardized Single Case Agreement Sample Letter removes guesswork and ensures you include every detail insurance adjusters require to approve your request.

Every effective SCA request letter includes these non-negotiable components:

Letter Section Purpose
Patient Identifiers Confirm policy membership and eligibility
Provider Credentials Verify the specialist is qualified for your care
Medical Justification Explain why in-network options are insufficient
Requested Terms State clear dates and service limits for the agreement

Before drafting your letter, gather these items first:

  • Your full insurance policy number
  • Written referral from your primary care doctor
  • Proof that no in-network provider can deliver this care
  • Contact information for your requested out-of-network provider

Many people submit handwritten notes or generic emails and get denied for missing information. Using a tested sample eliminates these avoidable mistakes. You will still customize the letter for your unique situation, but you will start with a proven foundation.

Single Case Agreement Sample Letter For Mental Health Therapy

Date: [Insert Date]
To: Member Services Department, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Your Full Name]

Dear SCA Review Team,

I am writing to formally request a single case agreement for weekly outpatient mental health therapy with Dr. Lisa Marquez, LCSW. Dr. Marquez has specialized training in complex PTSD, a condition no in-network provider on my plan is certified to treat.

My primary care physician has documented this medical necessity on the attached referral. I request this agreement cover 12 weekly sessions beginning October 15, 2024. Please contact me at [phone number] with any questions.

Sincerely,
[Your Signature]
[Your Printed Name]

Single Case Agreement Sample Letter For Specialty Medical Surgery

Date: [Insert Date]
To: SCA Review Unit, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Your Full Name]

Dear Review Team,

I request a single case agreement for robotic spinal fusion surgery with Dr. James Hale at Regional Specialty Hospital. No in-network neurosurgeon on my plan has performed over 50 of this exact procedure, which carries significant risk for inexperienced providers.

Attached you will find surgical notes, peer outcome data, and my primary physician referral. I request coverage for this procedure scheduled for November 2, 2024.

Respectfully,
[Your Signature]
[Your Printed Name]

Single Case Agreement Sample Letter For Autism ABA Therapy

Date: [Insert Date]
To: Behavioral Health Department, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Child Full Name, DOB]

Dear SCA Team,

This letter requests a single case agreement for 30 hours weekly applied behavior analysis (ABA) therapy with Sunny Days Autism Clinic. The only in-network ABA provider has a 9 month waiting list, and early intervention is medically required for my child’s diagnosis.

Attached are the autism evaluation report, pediatrician referral, and waiting list confirmation. This request is for a 6 month agreement starting immediately.

Thank you,
[Parent/Guardian Name]
[Contact Phone]

Single Case Agreement Sample Letter For Out Of Network Physical Therapy

Date: [Insert Date]
To: Member Services, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Your Full Name]

Dear Review Team,

I am requesting a single case agreement for post-knee replacement physical therapy with Peak Sports Rehabilitation. All in-network PT providers have confirmed they do not offer the specialized aquatic therapy my surgeon has ordered for my recovery.

This request covers 24 sessions over 8 weeks. Attached is the surgeon’s treatment order and confirmation from all three in-network PT clinics.

Sincerely,
[Your Signature]
[Your Printed Name]

Single Case Agreement Sample Letter For Substance Use Treatment

Date: [Insert Date]
To: Behavioral Health Review, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Your Full Name]

Dear SCA Team,

I request a single case agreement for 90 day residential substance use disorder treatment at Northwood Recovery Center. In-network residential facilities do not offer the dual diagnosis mental health support required for my safe recovery.

Attached is my psychiatric evaluation, primary care referral, and admission date confirmation. Please expedite this request.

Respectfully,
[Your Signature]
[Your Printed Name]

Single Case Agreement Sample Letter For Chronic Pain Management

Date: [Insert Date]
To: Medical Review Department, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Your Full Name]

Dear Review Team,

This letter requests a single case agreement for monthly pain management appointments with Dr. Elena Torres. Dr. Torres is the only provider within 100 miles certified to perform the nerve block treatments that have successfully managed my neuropathy.

Attached is my 2 year treatment history and current pain specialist referral. This request is for a 12 month agreement.

Thank you,
[Your Signature]
[Your Printed Name]

Single Case Agreement Sample Letter For Pediatric Specialist Care

Date: [Insert Date]
To: Pediatric Services, [Insurance Company Name]
Policy Number: XXX-XXXX-XXXX
Patient: [Child Full Name, DOB]

Dear SCA Review Team,

I am requesting a single case agreement for pediatric cardiology care with Dr. Robert Kim at Children’s National Hospital. My child was born with a rare heart defect that no in-network pediatric cardiologist has experience treating.

Attached are the neonatology referral, genetic test results, and upcoming appointment date. Please process this urgent request as quickly as possible.

Sincerely,
[Parent/Guardian Name]
[Contact Phone]

Frequently Asked Questions about Single Case Agreement Sample Letter

How long does it take for an SCA request to get reviewed?

Most insurance carriers complete SCA reviews within 7-10 business days. Urgent medical requests may receive a decision within 72 hours when marked on your letter.

Can a provider submit the SCA letter for me?

Yes, most providers will submit this request on your behalf. Always send a copy of the letter to your own insurance member portal for your personal records.

Do I need a doctor referral for an SCA?

Nearly all approved SCAs require formal medical justification from a licensed provider. Attaching this referral with your letter will drastically improve approval odds.

Will an SCA cover all costs for the provider?

A signed SCA will bill your services at your plan's standard in-network copay or coinsurance rates. Always confirm cost terms in writing before starting treatment.

Can I renew a single case agreement after it expires?

Yes, you may submit a renewal request 2 weeks before your original agreement ends. Include updated medical progress notes with your renewal letter.

What happens if my SCA request gets denied?

You have the right to file a formal appeal within 180 days of the denial notice. Use the same sample letter structure for your appeal with additional supporting documentation.

When should I send my SCA request letter?

Submit your request at least 14 days before your first scheduled appointment. This gives the insurance team adequate time to review and approve your request.

Can I use this sample letter for any insurance company?

This sample structure works for all major commercial insurance, Medicare, and Medicaid plans. Always check your plan handbook for any unique required forms.

Do I have to write my own SCA letter?

You do not need to draft this from scratch. Using a tested sample letter will save time and ensure you include all required information for approval.

A Single Case Agreement Sample Letter removes the most common barriers to getting the care you need. Every example and tip on this page is built from real approved requests, so you can stop guessing what insurance reviewers want. Even small mistakes in your request can result in unnecessary denials, so always use a structured template as your starting point.

Bookmark this page for future reference, and share it with anyone you know who is fighting for covered care. Before you send any request, double check that you have attached all supporting documentation and confirmed your policy number is correct. Taking this extra care will give you the best possible chance of a fast, positive approval.