Single Case Agreement in Medicaid: Getting Paid for a Ride Outside a Plan's Network

What a single case agreement is

A single case agreement, often called an SCA, is a one-time contract between a health plan and a provider that is not in the plan’s network. It covers one member and one service, or one episode of care, and the plan approves it in advance. Health Net’s non-participating provider page (last updated July 10, 2026) describes it this way, and adds a second use: a provider in the network for one line of business, such as commercial coverage, can get one to serve a member in a line it has no contract for, such as Medi-Cal.

The federal rule behind it is 42 CFR 438.206. When a Medicaid health plan’s network cannot provide a covered service to a particular member, the plan must cover that service out of network, adequately and on time, for as long as the network cannot provide it (paragraph (b)(4)). The plan must also require out-of-network providers to coordinate with it for payment, and make sure the member pays no more than in network (paragraph (b)(5)). A single case agreement is one way a plan puts that payment in writing.

One limit matters to ride companies. Some states run rides through a broker paid as a rides-only plan, called a NEMT prepaid ambulatory health plan. Under 42 CFR 438.9, only paragraph (b)(1) of 438.206, the duty to keep an adequate network under written agreements, applies to that kind of broker. The out-of-network duty in (b)(4) is not on its list. So the federal rule points you to the health plan, not the broker.

When a ride company might get one

A single case agreement fits a trip the plan’s network cannot cover. It applies where rides are part of the health plan’s benefits and the plan or its ride vendor cannot place the trip:

• A service level the network lacks. A stretcher or bariatric trip when the plan’s vendors have no vehicle or crew for it. See bariatric transportation and stretcher van.
• A long or out-of-area trip. The care at the other end can carry its own agreement. Texas makes its Medicaid health plans approve out-of-state transportation, at no charge to the member or the state, when the plan’s medical director verifies the care must happen out of state, and that includes care the plan approved under a single case agreement (Uniform Managed Care Manual chapter 16.4, version 2.0.1, effective August 1, 2021). See long-distance medical transport and out-of-state NEMT trips.
• A line of business you are not contracted for. You may have a contract with a plan for one kind of coverage but not its Medicaid members. Health Net’s example is a provider with a commercial agreement but no Medi-Cal agreement.

Not every program uses them. When Oklahoma’s out-of-state services rule changes began on September 1, 2019, the Oklahoma Health Care Authority said single-case agreements and contracts would not be allowed for SoonerCare out-of-state care, and members using them would move to regularly contracted providers.

If the plan keeps needing you, a single case agreement is a sign to apply for its network. See how to contract with Medicaid health plans and what to do when a broker network is full.

Do you need Medicaid enrollment for one?

Federal guidance says no. CMS’s Medicaid Provider Enrollment Compendium (section 1.13.3.C, last updated November 17, 2025) says out-of-network providers under single case agreements are not network providers, so the rule that states screen and enroll every network provider (42 CFR 438.602(b)) does not apply to them. They do not have to be screened or enrolled in the state’s fee-for-service program. Section 1.13.8 adds that states may, as a best practice, set a number of encounters after which the plan must convert an out-of-network provider to in-network status, which then requires screening and enrollment.

States can go further, and Ohio does. The Ohio Department of Medicaid’s memo of March 31, 2026 says plans may pay only providers enrolled with the state and active in its Provider Network Management (PNM) system, and that claims from unenrolled providers are rejected at the electronic front door. For a single case agreement, the provider has three routes:

1. The PNM application. Choose the “MCP Single Case” tile in PNM. Once approved, you get a typical 5-year provider agreement.
2. Paper forms. If you will not apply online, complete ODM forms 10282 and 10283 and give them to the plan, which sends them to the state.
3. A one-time short agreement. Complete the simplified ODM 10295 form through the plan. It gives a single 120-day provider agreement, and you can have only one.

Under the same memo, a plan may hold your claim until enrollment is done. If you refuse every route, the plan may deny the claim 180 days after its first outreach, with reason code 226 and remark code N767. See Ohio for the rest of the state’s rules.

What to get in writing before the trip

1. Who and what is covered. The member’s name and member ID, the trip dates, the pickup and drop-off addresses, and the service level. An agreement covers one member and one service or episode, so a return trip or a second appointment may need its own approval.
2. The authorization number. Health Net requires prior authorization for all claims from non-contracting providers, except in certain emergencies. The number goes in box 23 of the CMS-1500 or its electronic match. See prior authorization.
3. The rate and what it includes. Base rate, mileage, wait time, an attendant, and any after-hours charge. Anything not written down may not be paid.
4. How to bill. Ask for the claim format and the claims address. Health Net wants a paper claim with a copy of the agreement attached, on the original red-and-white form, and rejects black-and-white, handwritten, or nonstandard forms.
5. The filing limit. Health Net processes claims received within 180 days after the date of service, or after the primary payer’s explanation of benefits when it is the secondary payer. Other plans set their own limits. See timely filing limit.
6. Any state enrollment step. In Ohio, finish one of the three routes above before you bill.

Keep a signed copy of the agreement with the trip log.

A billing example: one stretcher trip

Say a Medicaid health plan has a member who needs a stretcher ride to a specialist 80 miles away, and no vehicle in its network can take the trip. The distances are example numbers. The plan offers you a single case agreement.

Before dispatch, you get a signed agreement naming the member, the date, and the round trip, with a per-trip rate and a per-mile rate, and the authorization number. After the ride, you bill exactly what the agreement covers: the stretcher trip and the loaded miles, with the authorization number in box 23. If the plan follows rules like Health Net’s, you mail a paper CMS-1500 with the agreement attached, well inside the 180-day limit. The plan pays the agreed rate, and the member owes nothing beyond what an in-network trip would cost.

How it differs from a network agreement

• Scope. A network provider agreement lets you serve the plan’s members over time. A single case agreement covers one member and one service or episode.
• Credentialing. Network providers go through the plan’s documented credentialing and recredentialing (42 CFR 438.214). At Health Net, a single case agreement rests on a prior authorization from the plan.
• State enrollment. The state must screen and enroll every network provider, and a plan may sign a network agreement for up to 120 days while that is pending (42 CFR 438.602(b)). Out-of-network providers are outside that federal rule, though states such as Ohio require enrollment anyway.
• Pay. A network contract sets a rate sheet for all trips. A single case agreement sets the pay for that one case.

For how plans check whether their networks are big enough, see network adequacy.