Single Case Agreements for TMS

What Is a Single Case Agreement?

A single case agreement (SCA) is a one-time deal between an out-of-network provider and an insurance company to cover a specific patient’s treatment at a negotiated rate. For TMS, SCAs come up a lot — many insurance networks simply don’t have enough in-network TMS providers to go around.

If your patient’s insurance covers TMS but there’s nobody in-network within a reasonable distance, an SCA may be the best way to get treatment paid for.

When to Pursue an SCA

An SCA makes sense when:

• The patient’s plan covers TMS therapy
• There are no in-network TMS providers within a reasonable distance (typically 30–60 miles)
• The patient already has prior authorization for TMS
• The out-of-network costs would be too much for the patient (high coinsurance or deductible)

Step-by-Step Process

Step 1: Verify the Network Adequacy Gap

Call the patient’s insurance and document:

• How many in-network TMS providers exist in the patient’s area
• The closest in-network TMS provider and how far that is from the patient
• Whether the plan has a network adequacy requirement

Get a reference number for this call. If the rep confirms no in-network TMS provider is available, that’s the foundation of your SCA request.

Step 2: Get Prior Authorization First

Most carriers want prior auth before they’ll even look at an SCA. Get the TMS treatment authorized through the standard process. The auth establishes medical necessity — the SCA only addresses the network gap.

Step 3: Submit the SCA Request

Contact the carrier’s provider relations or network management department. You’ll need:

• Patient demographics and insurance ID
• Prior authorization number for TMS
• Documentation of network inadequacy — reference number from Step 1
• Your proposed rate — typically 100–120% of Medicare rates
• Your credentials — NPI, license number, TMS device information
• Clinical justification — a letter explaining why this patient needs TMS and why they can’t get to an in-network provider

Step 4: Negotiate Terms

The carrier will counter-offer. Here’s what to push for:

Step 5: Get Everything in Writing

Do not start treatment based on a verbal agreement. Get a written SCA that spells out:

• Agreed reimbursement rates per CPT code (90867, 90868, 90869)
• Total number of authorized sessions
• Effective dates
• Patient cost-sharing terms
• Claims submission instructions and timely filing requirements

Tips for Success

1. Frame it as the carrier’s obligation — most state insurance regulations require network adequacy. The carrier has a duty to provide access to covered services.

2. Include distance data — if the nearest in-network provider is 90 miles away, spell out the hardship. TMS requires 5 visits per week for 6+ weeks. That’s a lot of driving.

3. Be reasonable on rates — asking for 150% of Medicare is fair. Asking for your full billed charges will probably get rejected.

4. Document everything — save every email, letter, and call log. If the carrier drags its feet, file a complaint with your state’s department of insurance.

5. Know the patient’s appeal rights — if the carrier refuses an SCA, the patient can file a grievance. External review of network adequacy complaints often sides with the patient.

Common Reasons SCAs Get Denied

• An in-network provider exists (even if they’re far away or have a long wait)
• The plan doesn’t cover TMS at all — an SCA can’t create coverage that isn’t there
• Missing prior authorization — always get auth first
• Provider credentials issue — make sure your license and NPI are clean

State Laws That Help

Several states have laws that strengthen SCA requests:

• California — Timely Access Regulations require plans to provide access within specific timeframes
• New York — Surprise Bill Law provisions can support SCA requests
• Texas — Network adequacy standards require minimum provider-to-patient ratios
• Illinois — Network adequacy requirements enforced by the Department of Insurance

Check your state’s insurance regulations for network adequacy rules that back up your request.

Additional Resources

For questions about specific legal or regulatory requirements in your state, consult with a healthcare attorney familiar with neuromodulation practices. The legal landscape for TMS is evolving rapidly as the technology becomes more mainstream.

Additional Resources

For questions about specific legal or regulatory requirements in your state, consult with a healthcare attorney familiar with neuromodulation practices. The legal landscape for TMS is evolving rapidly as the technology becomes more mainstream.