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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.

Your deadline

No fixed deadline of its own, but it runs alongside your appeal — so the 180-day internal-appeal window from receipt is still the clock that matters.

This is not everyone’s clock. Medicaid or CHIP, Medicare, TRICARE, VA health care and a church or government employer plan run on different rules. Do not assume the number above is yours.

Medicaid or CHIPMedicareTRICAREVA health carea church or government employer plan
Work out your own deadline
Count the providers near youA single case agreement is easier to argue for when you can show how few providers exist and how few of them your plan covers.

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.

If this has already happened to you

Losing money you did not have on a surgery you were told was approved is its own kind of injury, and the fact that it was preventable makes it worse rather than better. It was not carelessness. Two documents that sound identical, and everyone in the conversation saying approved.

The claims are not necessarily dead: the provider can pursue reprocessing, an appeal about what you were told is a different argument from an appeal about coverage, and a state insurance department will take a complaint about it. If you are having a hard time with this, Trans Lifeline is peer support run by trans people, at (877) 565-8860 in the US and (877) 330-6366 in Canada, and they have a stated policy against nonconsensual active rescue.

The failure this page exists to prevent

The pattern has been reported publicly. NPR covered a case in April 2024: a patient went into surgery with an approval in hand, put up about fourteen thousand dollars expecting reimbursement to follow, and never got it — because what existed was an authorization, not an executed out-of-network payment agreement.

That is a real reported case rather than a composite, and nobody connected to this site. The person is not named here: the figure comes from a story we could not re-read from the source, and attaching a private individual's name to a number we could not re-verify is not something a page about other people's money should do.

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

Sources for the legal points on this page

Also on this page, without a citation yet

  • The NPR report itself was not re-read for this page. It is named in the research this site was built from, with the outlet, the person, the insurer and the month, so it is checkable — but we could not reach the story from this machine to confirm the figure against the source. Treat the number as reported rather than verified.
  • That a plan will tell you whether an agreement is executed if you ask plainly. It should, and the whole page rests on asking, but no rule we can cite obliges a plan to volunteer the status of a contract between it and your provider. Ask the PROVIDER'S billing office as well; they are a party to it.

These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.

Last updated 2026-08-09Not legal or medical advice