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Single case agreements: an approval is not a promise to pay

A single case agreement is a contract between your plan and an out-of-network surgeon setting what the plan will pay for your procedure. A prior authorization is not one. People have paid tens of thousands of dollars on an approval that was never an executed payment agreement, and never been reimbursed.

Applies to Any plan where your surgeon is out of network. Insurers also call these letters of agreement.

What to do

  1. Understand what you are missing

    Prior authorization says the care is medically necessary. A single case agreement says what the plan pays whom. You can hold the first and have nothing resembling the second.

  2. Ask for the agreement explicitly, by name

    Ask the plan and the surgeon's billing office whether a single case agreement or letter of agreement is being negotiated for your procedure.

  3. Ask whether it is executed, in writing

    In negotiation, offered, and executed are three different states. Only executed means signed by both sides. Get the answer in an email you keep.

  4. Get the terms, not just the fact

    The rate, the procedure codes covered, the dates it is valid for, your cost share, and whether the surgeon has agreed not to balance bill you.

  5. Do not pay a large deposit until it is executed

    This is the step where the money is lost. If a deposit is required before the agreement exists, you are the one carrying the risk.

  6. Get a gap exception too if the issue is network adequacy

    The gap exception sets your cost sharing; the single case agreement sets the plan's payment. They are different documents and you may need both.

The failure this page exists to prevent

The pattern has been documented publicly: a patient with an approval in hand pays roughly fourteen thousand dollars out of pocket for surgery, on the understanding that reimbursement will follow, and the reimbursement never comes, because what existed was an authorization rather than an executed out-of-network payment agreement.

Nobody sets out to make this mistake. It happens because the two documents sound alike, and because everyone in the conversation uses the word approved.

Common questions

Is prior authorization the same as a single case agreement?
No. Prior authorization is a medical-necessity decision. A single case agreement is a payment contract with an out-of-network provider. Holding one tells you nothing about the other.
What one question should I ask?
Ask in writing: is there an executed single case agreement in place for this procedure with this surgeon, and what are its terms? Keep the reply.

Where to go next

Last updated 2026-08-06Not legal or medical advice