Single-Case Agreement: Get In-Network Coverage When No Specialist Is Available
How to request a network-gap exception so out-of-network specialty care is processed at in-network rates.
What a single-case agreement does
A single-case agreement is a one-off arrangement between your insurer and an out-of-network provider when no clinically appropriate in-network option is reasonably available. If approved, your care is typically processed closer to in-network terms for a defined service window. This can significantly reduce your patient responsibility and limit surprise balances. It is especially relevant for specialized surgery, complex behavioral health, rare disease care, and pediatric subspecialties.
When to request a network-gap exception
Request the exception before treatment whenever possible. The strongest cases document that in-network options are unavailable, have excessive wait times, are outside safe travel distance, or do not offer the required expertise. Ask your provider to include a brief clinical rationale explaining why this specific specialist is medically appropriate and time-sensitive. The request is stronger when patient and provider submissions tell the same story.
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Most plans want the diagnosis, proposed treatment, expected dates of service, provider credentials, and evidence of failed in-network access attempts. Include names and dates for in-network offices you contacted, wait times offered, and why they were not viable. If your plan has a dedicated form, use it and attach a concise support letter. Missing network-access evidence is one of the most common reasons these requests are denied.
How to follow up without losing momentum
After submission, call member services every few business days for status and record reference numbers. If timelines slip, request escalation to utilization management or case management. Ask for written decisions and the exact effective dates if approved. When partially approved, confirm which services are included and whether facility and professional fees are both covered under the same agreement.
Appeal strategy if the exception is denied
If denied, file an appeal focused on access barriers and medical necessity rather than general fairness language. Re-submit documentation showing unavailable in-network options and include clinician letters with specific urgency and specialty requirements. Ask your provider office whether they can support a peer-to-peer review. In many cases, denials are reversed once the insurer sees stronger access evidence tied to clinical risk.
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FAQ
Is a single-case agreement the same as prior authorization?
No. Prior authorization approves medical necessity; a single-case agreement addresses network status and reimbursement terms.
Can I request this after I already received care?
Sometimes, but approval is harder post-service. Pre-service requests generally have better outcomes.
Who should submit the request, me or my provider?
Both can help. Provider-led submissions with detailed clinical context often perform best, but patient documentation of network-access barriers is also critical.