Guide to Single Case Agreements & Network Gap Extensions- Insurance Coverage for Counseling
April 18, 2025 | By Carissa Hannum
This is a repost of our blog originally posted in 2024.
Accessing specialized trauma, mood disorder, and eating disorder treatment can be challenging, especially when many expert providers do not accept insurance. In the Washington, DC area and beyond, clients often express frustration that highly specialized therapists are considered out-of-network (OON) providers.
Many providers choose not to accept insurance due to restrictive oversight, which can limit treatment options and dictate outcomes. However, clients have the option to advocate for a Single Case Agreement (SCA) or Network Gap Extension with their insurance provider. This guide will walk you through the process of securing one of these agreements to help you access the care you need.
What is a Single Case Agreement (SCA) or Network Gap Extension?
A Single Case Agreement (SCA) is a contract between an out-of-network provider and an insurance company that allows a client to receive care at in-network rates. Similarly, a Network Gap Extension (also called a clinical gap exception, out-of-network exception, or gap waiver) is an agreement between the client and their insurance provider to cover services from an OON provider at a negotiated rate.
These agreements are often granted when in-network providers are unavailable, have long wait times, or lack the specialized training required for ethical and effective client care. SCAs and gap extensions are typically approved for a specific duration and fee structure, with the possibility of renewal upon expiration.
Steps to Request a Single Case Agreement or Network Gap Extension
1. Contact Your Insurance Provider
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Clients should call their insurance company using the number on the back of their insurance card and request a Single Case Agreement or Network Gap Extension. Be prepared with the following details, which can be found on your superbill or obtained from your clinician:
CPT/Procedure Code for services
Diagnosis Code related to treatment
Out-of-Network Provider’s Name & Contact Information
Start and End Dates for services
Reason an In-Network Provider Cannot Provide the Required Care
2. Provider Involvement (If Required)
Insurance companies may request a brief (10-15 minute) phone call with the provider to verify treatment details and justify the need for specialized care. However, the process varies, and providers may or may not be contacted directly.
3. Approval Timeline
The approval process typically takes 2-3 weeks, though some clients receive approval on the first call, while others must follow up multiple times. If you do not hear back, continue calling your insurance provider to check on the status of your request.
Understanding Payment with a Single Case Agreement
Even after securing an SCA or gap extension, payment remains the client’s responsibility. The provider will continue issuing superbills, and the client must submit them to the insurance company for reimbursement.
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Clients should be prepared for potential billing complications, including:
Incorrect Claim Processing: Some insurance companies mistakenly process claims as OON, despite the agreement.
Reimbursement Discrepancies: Insurance may attempt to pay only a “customary” rate, which can be significantly lower than the provider’s fee. Clients should ask about the company’s Balanced Billing Policy, which may require the insurance provider to cover the full negotiated rate.
Additional Considerations for Clients and Providers
1. Diagnosis Matters
Certain diagnoses, such as eating disorders, often strengthen the case for approval, as specialized providers are scarce within many insurance networks.
2. Framing the Need for Services
Clients should clearly explain why they require a specific provider. Example: “I need an eating disorder specialist, and I cannot find any in-network providers with this specialty.”
Providers should highlight their expertise and explain why their approach is necessary for ethical and effective treatment. Example: “I specialize in eating disorder treatment and EMDR therapy, which this client specifically needs because…”
3. Addressing In-Network Provider Lists
Insurance companies may send a list of in-network providers in an attempt to deny the request. Clients should research these providers and, if necessary, respond with:
“I contacted these providers, and they do not offer the specialty I need.”
“These providers have long waitlists, and I need treatment immediately.”
4. Paperwork and Documentation
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SCAs and gap extensions are agreements between the client and their insurance company, not the provider. Providers may need to participate in a phone call but typically do not complete additional paperwork. Clients should verify that any documents they receive do not inadvertently place the provider under an in-network contract.
Helpful Insurance Resources for Clients
Physician Fee Schedule Guide by the Centers for Medicare and Medicaid: CMS Fee Schedule
Project HEAL’s Insurance Navigation Resource Guide: Insurance Guide
Final Thoughts
While navigating insurance for specialized mental health care can be frustrating, advocating for a Single Case Agreement or Network Gap Extension can make expert treatment more accessible. Clients should be persistent, document all interactions, and seek support from their providers when needed.
If you are struggling to access care, Monarch Wellness & Psychotherapy is here to help. Our team can guide you in advocating for the coverage you deserve. Contact us today to learn more about our specialized services.
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