How to request a single case agreement as an out-of-network therapist

A therapist asks the member's plan for a single case agreement, the contract a plan may sign so one member keeps an out-of-network therapist. No federal rule makes it a member's right or sets its form or clock. In Medicaid, 42 CFR 438.206(b)(4) has a plan whose network cannot serve an enrollee cover the service out of network.

What is a single case agreement, and who decides?

A single case agreement is a contract that lets a managed care plan pay a provider for one member, or a selection of members, without the provider signing the plan's broader network contract. A toolkit for state Medicaid agencies on Medicaid.gov gives that definition, and the toolkit is guidance and not a regulation. The plan decides whether to sign one.

The toolkit's example Medicaid contract language gives a plan three routes when a new member's out-of-network behavioral health provider needs to continue: add the provider to the network, implement a single case agreement, or help the member find an in-network provider. No federal rule or federal guidance names a form, a channel or a decision clock for a single case agreement, so each plan's own instructions govern the request.

When does a Medicaid plan have to pay an out-of-network therapist?

A Medicaid managed care plan whose network cannot provide a covered service to a particular enrollee has to cover it out of network until the network can, at no greater cost to the enrollee (42 CFR 438.206(b)(4)-(5)).

A second rule protects a member who changes plans. 42 CFR 438.62(b) requires each state to have a transition of care policy for enrollees moving from fee-for-service to managed care, or from one plan to another, when losing services would cause "serious detriment to their health" or leave the enrollee "at risk of hospitalization or institutionalization." The policy must let the enrollee keep a current provider for a period of time if that provider is not in the plan's network. The state must publish the policy and give enrollees instructions on how to get continued services.

What goes in a single case agreement request?

A single case agreement request for a Medicaid member should show three things: the plan's network cannot provide the service to this member, the treatment relationship already exists, and stopping care would cause "serious detriment to their health" or put the member "at risk of hospitalization or institutionalization." The first rests on 42 CFR 438.206(b)(4) and the third on the transition of care rule in 42 CFR 438.62(b). A request that asks the plan to consider an agreement, and leaves the plan its other two routes, treats the agreement as the plan's option. A letter from the treating clinician can carry the harm statement, sent the way how to fax a letter of medical necessity describes.

The table lists each step or document in a single case agreement request, where it goes, the rule that applies and the official source.

How do you send the request and prove it arrived?

A single case agreement request goes by the channel the member's plan names in its own instructions, because no federal rule or federal guidance names fax or any other channel for one. For a member who is changing plans, the state's published transition of care policy carries the state's instructions for getting continued services. A therapist who sends by fax prints a monitored fax number on the request so the plan's answer has somewhere to land. The delivery record stays with the request, and how to tell if a fax went through explains what counts as proof.

How long does the plan have to answer?

No federal rule sets a decision clock for a single case agreement. The 7-day figure in the Medicaid managed care rules times a service authorization, such as the prior approval North Carolina requires before non-emergency out-of-network care: the plan decides a standard request within 7 calendar days in rating periods beginning on or after January 1, 2026 (42 CFR 438.210), and that clock never reaches the agreement itself.

The transition of care rule says only that an enrollee may keep a current provider for a period of time. The state's published policy, with its instructions, is where the length is read.

What gets a single case agreement request delayed or turned down?

A single case agreement request is delayed or turned down when care starts before the required prior approval, when the request reads as a demand, when it is too vague for the plan to act on, and when it overlooks the limits of the plan type.

• North Carolina Medicaid requires out-of-network providers to get prior approval from the member's health plan before providing services other than emergency and post-stabilization care, and says they may need a single case agreement to be paid (NC Medicaid's guide for providers).
• The agreement is the plan's option, so a request written as a right gives the plan a reason to choose another route.
• A vague request, since a commercial plan can return its network exception form for completion when entries are missing, general or illegible.
• North Carolina's Tailored Plans and NC Medicaid Direct may keep a closed network for behavioral health services and may require an out-of-network agreement to pay, and a plan may not pay an out-of-network provider more than 90% of the Medicaid fee-for-service rate for services other than emergency and post-stabilization care.

How do Medicare Advantage, exchange plans and Texas handle the same job?

Medicare Advantage, Federally-facilitated Exchange plans and Texas preferred provider plans each have a rule that can make a single case agreement unnecessary.

• Medicare Advantage: a plan must give an enrollee who joined after starting a course of treatment a transition period of at least 90 days for any active course of treatment, even when the provider is out of network (42 CFR 422.112).
• Federally-facilitated Exchange plans: when a plan ends a provider's contract without cause, an enrollee in an active course of treatment continues until treatment is complete or for 90 days, whichever is shorter, at in-network cost sharing (45 CFR 156.230). An active course of treatment includes one where the treating provider attests that stopping care with that provider would worsen the condition or interfere with anticipated outcomes.
• Texas: a preferred or exclusive provider plan pays a non-preferred provider at the preferred provider's percentage level when no preferred provider in the service area offers the service (Insurance Code 1301.005(b)).

A commercial plan may take a network exception request on its own form, as Evernorth does with its Outpatient Behavioral Network Exception Request Form, and a therapist who would rather join the network follows insurance credentialing paperwork by fax. In a recent plan transition, Iowa required exiting Medicaid plans to tell receiving plans which providers held single-case agreements for transitioned members.

How do you send a single case agreement request securely, and where does the answer land?

A therapist faxes a single case agreement request securely through a HIPAA fax service that has signed a BAA, and prints the practice's own fax number on the request so the plan's answer lands there. Fax Pigeon signs that BAA at signup on every plan and sends from the browser or from email, and on a paid plan the request goes out from the practice's own number. The plan's answer arrives in a shared inbox with roles and assignment, where whoever handles the request picks it up, and each delivered fax gets delivery proof to keep with a copy of the request. A cover sheet is optional.

* Official sources (Medicaid.gov, the eCFR, North Carolina Medicaid, the Texas Legislature, Evernorth) were read on October 26, 2026. Fax Pigeon prices and plan terms as of October 26, 2026.