How do you get a single case agreement for ABA with an out-of-network payer?

What is a single case agreement, and what do payers actually call it?

A single case agreement is a short contract between one out-of-network provider and one payer, covering one patient for a fixed set of codes, units and dates. The family is billed at the in-network benefit level and you are paid at a rate the two of you agree in writing. It does not make you in-network for anyone else.

Here is the part that costs practices weeks: no major national payer publishes a policy page using that phrase. UnitedHealthcare publishes a Network Gap Exception Request Form for cases where there are not enough clinicians in a local area or specialty. Cigna and Evernorth run a Network Adequacy Provision plus an Outpatient Behavioral Network Exception Request Form, which asks for diagnosis, CPT codes, service location and total hours requested. Call a behavioral health line and ask for a single case agreement and you may be told there is no such thing. Ask for a network exception and you get the form.

Cigna’s published behavioral health distance standard is 15 miles in urban and suburban areas and 25 miles in rural areas, against 25 miles for primary care and physician specialties. That number is the standard your network search has to beat.

When will an out-of-network payer grant one for ABA?

Three situations carry almost all approvals: the plan has no in-network BCBA who can take the child inside its own access standard, the child is already in treatment with you and the plan changed underneath the family, or the child needs something the network cannot deliver, such as severe destructive behavior work billed under 0362T and 0373T.

The second case is the easiest win and the one practices under-use. A family that switched employers in March should not have to restart a behavior plan, and continuity arguments are cheap for a payer to approve.

Single case agreement Medicaid rules and EPSDT

Medicaid managed care is not a weaker case, it is a stronger one. Under 42 CFR 438.206(b)(4), if the provider network cannot deliver a covered service to a particular enrollee, the plan must cover that service out of network, adequately and timely, for as long as the network cannot provide it. Paragraph (b)(5) then requires the plan to coordinate payment with the out-of-network provider and to keep the enrollee’s cost no higher than it would be in network.

Layer EPSDT on top. For an enrollee under 21, section 1905(r) of the Social Security Act entitles the child to any medically necessary service that can be covered under federal Medicaid to correct or ameliorate a condition, whether or not the state plan lists it. CMS applied that directly to autism services in its July 2014 informational bulletin. A state Medicaid MCO with no in-network BCBA within reach of a nine year old is not exercising discretion, it is out of compliance. Write the request in those terms.

California shows what a clean version looks like. DHCS All Plan Letter 15-025 requires Medi-Cal managed care plans to offer continuity of care with an out-of-network behavioral health treatment provider for as long as 12 months, and sets the minimum agreed rate at the established Medi-Cal fee-for-service rate. That is a published rate floor you can quote back.

How do you request a single case agreement from an insurance company?

Work the sequence below in order. Skipping the first step is the single most common reason a request stalls in clinical review.

1. Run and log the network search. Call every in-network ABA provider the plan’s directory lists inside its distance standard. Record the date, the practice name, who answered, the waitlist in weeks, and the driving distance. Ten calls with dates beats any paragraph of argument.
2. Verify benefits before you ask. Run a 270 eligibility request and read the 271 back for out-of-network benefits, an autism carve-out, a separate behavioral health administrator, and whether the plan is self-funded or fully insured. A self-funded ERISA plan is administered by a third party and escalates to the Department of Labor, not the state insurance department.
3. Get the right form. Ask the behavioral health line for the network exception or network gap exception form, not for a single case agreement.
4. Submit the clinical packet. Diagnosis, the assessment report behind 97151, the treatment plan with recommended hours by code, the network search log, and the requested start date. Cigna’s behavioral form asks for total hours requested, so bring that number ready.
5. Negotiate the rate code by code. Never accept one blended rate across the whole code set. More on this below.
6. Get the countersigned agreement and the reference number. A verbal approval is not payable. You need the document and the identifier the claims system will match against.
7. Test with one claim. Send a single 837 for one date of service and read the 835 before you release the backlog.

In our experience the stages run roughly three days to log the network search, five days to get a case manager assigned, nine days in clinical review, seven days negotiating the rate, and four days to get the countersigned copy back. That is about 28 business days end to end, and clinical review is where the time goes.

Our eligibility and prior authorization team runs the 270 and 271 checks and the network search log for ABA clients, which is what turns a four week request into a three week one. See how we handle eligibility and prior authorization.

What are realistic single case agreement rates for 97151, 97153 and 97155?

Start from a published number, not from a percentage. All ten adaptive behavior codes, 97151 through 97158 plus 0362T and 0373T, are 15 minute timed codes. There is no per-session code in the family, so every rate conversation is a conversation about a quarter hour.

Two state Medicaid programs give you a defensible floor and a defensible ceiling. Florida’s 2026 Behavior Analysis Fee Schedule pays $12.19 a unit for 97153 and $19.05 for both 97151 and 97155. Indiana’s rates effective 1 April 2026 pay $16.04 a unit for 97153 and $25.97 at the top tier for 97151 and 97155. That is a 32% spread between two state programs for the identical code, which is your evidence that a payer’s first offer is a position, not a fact.

The chart shows Florida at $12.19 and Indiana at $16.04 a unit for 97153, and $19.05 against $25.97 for 97155.

Why one blended rate always loses

Ask for a single number across the code set and the payer will average toward the technician line, because that is where the volume sits. A child at 25 hours a week of 97153 burns 100 units a week. Two hours of 97155 is eight. A blended rate anchored on the technician rate gives away the BCBA line entirely. Quote four numbers: 97151, 97153, 97155, 97156. Add 97154 and 97158 only if you run groups.

A worked example at 26 weeks

Take one child authorized for 25 hours a week of 97153 for 26 weeks, two hours a week of 97155, and an eight hour 97151 assessment. That is 2,600 units of 97153, 208 units of 97155 and 32 units of 97151. At Florida Medicaid rates the episode is worth $36,266. At a rate 30% above that floor, $15.85 for 97153 and $24.77 for 97155 and 97151, it is worth $47,154.80. The gap is $10,888.80 on one child. Thirteen hours of staff time to negotiate and clean up the first claims, at a loaded $48 an hour, costs $624. Net, $10,264.80.

That arithmetic is also the answer to whether the effort is worth it. One agreement pays for the work. Four of them a year, on the same payer, means you should be credentialing with that payer instead. New clinicians waited a median 96 days to go in-network with commercial payers in our billing reviews, so start that clock while the agreements carry the revenue. Our page on how long insurance credentialing takes has the payer by payer timelines.

What must the written agreement say before you sign it?

A signed agreement that omits any of the following will cost you money later. Treat this as your single case agreement template checklist.

• A rate per CPT code, written out, not a percentage of anything.
• The unit cap per code for the authorization period, and what happens when it is reached.
• Effective date and end date, with the retroactive start date if services already happened.
• The agreement or authorization reference number the claims system will recognise.
• The claims submission address or payer ID, which is often different from the standard one.
• The timely filing window that applies, in writing.
• The renewal trigger and how many days before expiry you must request an extension.
• Which entity pays: the plan, the behavioral health carve-out, or the third party administrator.

One trap worth naming. Under 42 CFR 422.520, a Medicare Advantage plan must pay 95% of clean claims from non-contracted providers within 30 days, but contracted providers are paid on the terms of their written agreement. The moment you sign, the federal 30 day floor may stop applying and your agreement’s own payment terms govern. Read that clause before you sign it, not after.

Why does the first claim under a new agreement deny?

Because the payer’s claims system still has you flagged out-of-network while the contracting system has an agreement. You sit between the two, and the adjudication engine resolves that conflict against you.

Across our claim audit, eligibility and coverage errors caused 24% of denials, coding and modifier errors 21%, missing or invalid prior authorization 17%, duplicate claims 9% and timely filing 6%. On agreement claims the first three do most of the damage.

The fix sequence

Send one test claim, not the backlog. Put the agreement reference number where the payer told you to put it, in writing, because box 19 on the CMS-1500 is not universal. Check the rendering provider matches the credential tier in the agreement, because an RBT line submitted under the BCBA’s NPI will deny even when the rate is right. Read the 835 remittance rather than the portal summary: the portal shows paid or denied, the remittance shows the reason code. If the denial is an out-of-network flag, call the contracting contact who signed the agreement. The general claims line cannot change that flag.

Then work the rest of the episode properly. In our billing reviews 19% of denied claims were never reworked or appealed, and timely filing caused 6% of denials with only 4% of those recovered. Agreement claims are exactly the ones that get set aside as complicated and then age out. Our denials and AR recovery work exists for that pile, and clean claim rate and days in AR are the two numbers that tell you whether it is being worked.

What happens when the units run out or the request is denied?

Unit exhaustion is the more common problem and the more expensive one. Authorization unit overruns caused 29% of ABA denials in our claim audit, and ABA re-authorizations took a median 12 business days in our client data. Twelve business days is close to three calendar weeks of sessions you have already delivered. Track the unit balance weekly against the cap in the agreement and file the extension when 70% of units are consumed, not when they are gone.

If the request itself is denied, the ladder is: internal appeal, external review, then the regulator. On an ERISA group health plan the claimant has at least 180 days to appeal under 29 CFR 2560.503-1(h)(3)(i), and an external review request must be filed within four months of the adverse determination notice under 45 CFR 147.136(d)(2)(i). Appeals we filed were overturned 68% of the time in our client data, and appeals took a median 34 days from filing to payer decision.

The parity argument, used correctly

On 8 September 2026 the Department of Labor issued Field Assistance Bulletin 2026-03, setting out enforcement priorities for nonquantitative treatment limitations under the Mental Health Parity and Addiction Equity Act. Network adequacy standards, including network admission standards and provider reimbursement methodologies, are one of the three named priorities, and the accompanying compliance material flags disparate network gap or out-of-network exception processes as a red flag.

Be accurate about what is enforceable. The 2024 MHPAEA final rule at 89 FR 77586 is subject to a non-enforcement policy announced by the Departments on 15 May 2025 while the ERIC litigation proceeds, so plans may continue to rely on the 2013 rule. The statute, the 2013 rule and the comparative analysis requirement still apply. Cite those, not the 2024 provisions, and you will be on firmer ground than most of what is written about this.

One more accurate negative. The No Surprises Act does not protect routine outpatient ABA. Its non-emergency balance billing protections attach to services at a health care facility, defined at 45 CFR 149.30 as a hospital, hospital outpatient department, critical access hospital or ambulatory surgical center. Clinic, home and school based ABA is none of those, so federal independent dispute resolution is not available to you. What does apply is the good faith estimate requirement at 45 CFR 149.610 for uninsured or self-pay families, including families who have coverage and choose not to submit a claim.

If this is a recurring fight rather than a one-off, the whole revenue cycle around it has to hold, and the in-house versus outsourced choice is covered on our medical billing companies comparison. Outsourcing an ABA revenue cycle runs 3% to 6% of collections, a real cost to weigh. You can also send us your AR ageing report.

Single case agreement vs gap exception vs prior authorization

Four terms get used interchangeably and they are not the same instrument. Asking for the wrong one sends your request to the wrong queue.

In practice you often need two of them at once. The gap exception or agreement settles the money, the prior authorization settles the units, and neither substitutes for the other. Getting a signed agreement and no authorization produces a denied claim at an agreed rate, which is the worst of both.

ABA and behavioral health

The hardest version of this problem, because the code set is entirely 15 minute units and the credential tier changes the rate. Price 97151, 97153, 97155 and 97156 separately, and confirm whether the payer recognises a BCaBA tier, as Florida does with the HN modifier at $19.17 for 97155. Watch the concurrent 97153 and 97155 rules, because an agreement that is silent on concurrent billing will be read against you. More on the code set on our ABA billing page. For talk therapy alongside ABA, the same exception process runs through the behavioral health carve-out, covered on our psychology billing page.

Physical and occupational therapy

Agreements here usually turn on visit caps rather than unit caps, and the 8 minute rule decides how many units a visit yields. Unit errors under that rule appeared on 9% of therapy claims in our claim audit, and an agreement priced per unit against a payer counting visits produces a reconciliation argument every month. Pin down whether the cap is visits or units in writing. Our physical therapy billing page covers the rest.

Dental

Dental practices rarely use this route for routine work, but it matters for medically necessary procedures cross-coded to CPT, where the medical plan has no in-network oral surgeon in range. The agreement has to name whether it is adjudicated on the medical or the dental benefit. Dental practices wrote off a median $23,400 a year in restorative claims denied for missing narratives or X-rays in our billing reviews, and an exception request needs the same documentation the claim will.

Ambulance and EMS

Emergency transport is one of the few places the No Surprises Act does reach ground and air ambulance differently, so read the setting before assuming an agreement is even needed. For non-emergency repeat transports the agreement question is usually about the Physician Certification Statement, which was missing or unsigned on 18% of non-emergency transports in our claim audit. No PCS, no agreement worth having.

Primary care and internal medicine

Rare, and almost always geography rather than specialty. The usable version is a transition of care request when a plan drops a practice mid year. Watch modifier 25: problem-oriented visits billed with an annual wellness visit lacked modifier 25 on 12% of claims in our audit, and those denials read as agreement failures when they are coding failures.