Single Case Agreement Template
Four documents and three sheets, arguing from the published network standard and the miles the nearest in-network provider sits beyond it.
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Adequacy Measurement Log
One row per request, measuring the gap rather than asserting it
This is the sheet the request is built on. Every column exists because a payer reviewer can check it, and the two derived columns on the right are the entire argument.
| Request | Payer | Specialty | Patient county | County type | Published max minutes | Published max miles | Nearest in-network minutes | Nearest in-network miles | Minutes excess | Miles excess | Directory read date | Accepting new patients | Standard cited |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The two derived columns
Minutes excess is the measured drive time to the nearest in-network provider of that specialty minus the maximum the plan publishes for that county type. Miles excess is the same subtraction in distance. Positive on either one is a measurable gap. Negative on both means there is no adequacy argument here, and the row says so.
Standard cited, and where it comes from
Either the plan's own published network standard or, for a Medicare Advantage plan, the time and distance table in regulation. Record which, because they are different numbers and the reviewer will check against the one you named.
Three columns for the second argument
Directory read date, accepting new patients, and waitlist quoted. A directory listing is not access if the practice is closed to new patients, and a fourteen week wait is the fact that makes a request about continuity of care rather than geography.
A single case agreement request that opens with how much the patient wants to keep seeing you does not get read twice. It arrives at a network operations queue, not at a clinician, and the two grounds that queue is staffed to act on are network adequacy and continuity of care. Both are measurable, and for a Medicare Advantage plan the yardstick is published: plans must meet maximum time and distance standards for each provider specialty, with the numbers set by county type rather than nationally.
So the request is built on a subtraction rather than an assertion. Measure the drive time and road distance to the nearest in-network provider of that specialty, subtract the maximum the plan publishes for that county type, and record both differences. Positive on either is a gap a reviewer can verify. Negative on both means there is no adequacy argument, and the log's first job is to stop that request from going out at all.
The second sheet compounds. Record every rate as a multiple of the published allowable rather than a dollar figure and each settlement becomes the next request's opening position. At Waverly Endocrinology the first Summit Advantage request opened at 1.50 times allowable, took two rounds and settled at 1.30, conceding 44.80. Seven weeks later a second opened at 1.30 and cleared in zero rounds. Denied requests are a different path, in the denial appeal pack.
What's in the pack
How the Adequacy Excess Is Measured
The method before the sheets: which standard to cite for which plan type, how to measure drive time defensibly, and the explicit limits of what an adequacy standard establishes.
Adequacy Measurement Log
One row per request with the published maximum, the measured distance, both excess columns, and the directory read date that a reviewer will check before anything else.
Single Case Agreement Request
The administrative request itself: patient, dates, codes, the measured gap, the rate asked as a multiple, and a signed clinical block the treating clinician fills in.
Justification Letter
The longer argument for when the request is queried, separating the geographic gap from the continuity argument so a reviewer can concede one without the other.
Rate Benchmark Register
Every rate asked and agreed, stored as a multiple of the published allowable so it transfers across codes, with the precedent each request leaned on named.
Follow-up Sequence
Touches on days three, ten, seventeen and twenty-four, with the escalation from an unnamed queue to a named network manager, which is the single biggest predictor of a timeline.
Request Tracker
Outcome, reviewer, decision date and the patient's scheduled care date, plus the denial reason recorded verbatim so the next request to that payer is written against it.
Where this stops and something else starts
Coverage of a specific service is a prior authorization question, handled by the prior authorization pack. What the plan says the patient has is eligibility and benefit verification.
How to use it
- 1
Open in River, or download it
Open the pack in River and let the agent assemble the request from the plan's published standard and your measurements, or download the blank Word and CSV files instantly.
- 2
Measure before you write anything
Nearest in-network provider of that specialty, in minutes and miles, against the maximum the plan publishes for that county type. Record the directory read date on the same row.
- 3
Let the log decide whether to send
Negative on both excess columns means no adequacy argument. Send it anyway and you spend four weeks getting a denial the sheet could have predicted on day one.
- 4
Open at what that payer already agreed
Take the opening multiple from the benchmark register rather than from a guess, then log the outcome and the reviewer's name so the next request starts further along.
Frequently asked questions
Is this template free?
Yes. The four documents and three sheets download as Word and CSV files with no signup and no card. "Edit with AI" is the optional path for practices that want the request assembled from their own measurements. The rest of the library is at the template library.
What format are the downloaded files?
Word documents for the method note, the request, the justification letter and the follow-up sequence, plus CSV for the three registers, zipped into one file. They open in Word, Pages, Google Docs, Excel, Numbers and Sheets with nothing to convert first.
What is the adequacy excess?
The measured drive time or distance to the nearest in-network provider of that specialty, minus the maximum the plan publishes for that county type. Two numbers, both subtractions, both checkable by the reviewer. A request where both come out negative is one the log tells you not to send.
Does an adequacy gap entitle the patient to see us?
No, and the pack is written to stop anyone implying it does. A network standard binds the plan to build a network, and the remedy runs between the plan and its regulator rather than to any individual provider. What the measurement does is give a reviewer a verifiable reason to agree.
Is there any rule that requires out-of-network coverage?
In Medicaid managed care there is one worth citing. If the network cannot provide a covered service to a particular enrollee, the plan must adequately and timely cover it out of network for as long as the network cannot. Read the actual plan contract before relying on it.
Why record the rate as a multiple rather than a dollar amount?
Because a multiple transfers and a dollar does not. In the worked quarter one settlement at 1.30 times allowable became the opening position for a request on a completely different code. A later request for the same code opened at 1.30 and was approved with no negotiation at all, which is two rounds saved on a single sheet lookup.
Does this decide anything clinical?
No. The clinical statement is a signed block the treating clinician completes, and the pack assembles the administrative case around it: the measurement, the rate, the clock and the outcome. Whether the care is appropriate, and whether the plan covers it at all, are separate questions this does not touch.
Find out whether you have an adequacy argument at all
Send the patient's county, the specialty, the plan and what its directory says. The first thing back is the measured gap against the published standard, and whether it is positive.
Edit with AI