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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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What you get

Pack of 7 files: 4 documents, 3 spreadsheets

Single Case Agreement Template
  • How the Adequacy Excess Is MeasuredDocument
  • Single Case Agreement RequestDocument
  • Justification LetterDocument
  • Follow-up SequenceDocument
  • Request TrackerSpreadsheet
  • Rate Benchmark RegisterSpreadsheet
  • Adequacy Measurement LogSpreadsheet
RiverSingle Case Agreement Template

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.

RequestPayerSpecialtyPatient countyCounty typePublished max minutesPublished max milesNearest in-network minutesNearest in-network milesMinutes excessMiles excessDirectory read dateAccepting new patientsStandard 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.

The request that should not have been sent, and the one that cleared in zero rounds

Six requests measured against the published standard, every rate recorded as a multiple, and the administrative clock against each patient's scheduled care date.

Single Case Agreement Template
RiverAdequacy Measurement Log

Adequacy Measurement Log

Illustrative rows for a fictional endocrinology practice, Waverly Endocrinology, across one quarter. Six requests, four counties, three county types. The last column is the outcome, and it tracks the excess columns exactly.

RequestPayerCountyTypeMax min.Max mi.Nearest min.Nearest mi.Min. excessMi. excessNew patientsWaitlistOutcome
SCA-109Ridgeline HealthKelsoMetro60404431-16-9Yes2 weeksDenied
SCA-118Summit AdvantageAshbourneMicro1007512896+28+21No14 weeksApproved
SCA-121Summit AdvantageAshbourneMicro1007512896+28+21No14 weeksApproved
SCA-124Cascade MutualMarlowRural11090141118+31+28Unknown, three callsNot quotedApproved
SCA-127Summit AdvantageAshbourneMicro1007512896+28+21No16 weeksApproved
SCA-131Summit AdvantageFenwickMetro60407152+11+12Yes6 weeksNo response

SCA-109 is the row worth studying, because it is the one the practice should not have sent. The nearest in-network endocrinologist was 44 minutes away against a 60 minute standard, accepting new patients, with a two week wait. Both excess columns are negative, the payer denied it in the reviewer's own words as in-network access within standard, and the patient rescheduled in network. Every request with a positive excess was approved or is still open. The log is a filter before it is an argument, and its first job is to stop the request that will be denied.

RiverRate Benchmark Register

Rate Benchmark Register

Every rate asked and every rate agreed, as a multiple of the published allowable rather than a dollar figure, because the multiple is what transfers to the next request. The precedent column is why this sheet exists.

RequestPayerCodeAllowableMultiple askedAskedMultiple agreedAgreedRoundsOutcomePrecedent used
SCA-109Ridgeline Health99205224.001.60358.40  2DeniedNone
SCA-118Summit Advantage99205224.001.50336.001.30291.202Approved at lower rateNone
SCA-121Summit Advantage99214116.001.50174.001.30150.801Approved at lower rateSCA-118 multiple
SCA-124Cascade Mutual9525138.001.5057.001.2045.602Approved at lower rateNone
SCA-127Summit Advantage99205224.001.30291.201.30291.200Approved at rate askedSCA-118 settled multiple

What the precedent column bought

RequestOpened atSettled atConcessionRoundsWhat changed
SCA-1181.50x1.30x44.802First request to this payer. Opened above and negotiated down.
SCA-1271.30x1.30x0.000Same payer, same code. Opened at what they had already agreed and it cleared on the first pass.

Two requests to the same payer for the same code, seven weeks apart. The first opened at 1.50 times the allowable, took two rounds, and settled at 1.30, giving up 44.80. The second opened at 1.30, took zero rounds and was approved at exactly what was asked. Recording the multiple rather than the dollar is what makes that transferable: SCA-121 was a different code entirely and still used the 1.30 that SCA-118 established. Without the register, every request opens at a guess and gets negotiated down again.

RiverRequest Tracker

Request Tracker

The administrative clock, with a touch recorded on days three, ten, seventeen and twenty-four. The scheduled care date is on the row because it is the deadline the follow-up sequence is actually racing.

RequestPayerPlan typeSubmittedReferenceReviewerDay 3Day 10Day 17DecisionCare dateCare proceeded
SCA-109Ridgeline HealthCommercial PPO2026-01-12RH-88421Network services queueConfirmedFile completeEscalated2026-02-09 denied2026-02-16Rescheduled in network
SCA-118Summit AdvantageMedicare Advantage2026-01-26SA-40117K Iyer, network managerConfirmedFile completeEscalated2026-02-13 approved2026-02-24Yes
SCA-121Summit AdvantageMedicare Advantage2026-02-16SA-40388K Iyer, network managerConfirmedFile complete 2026-02-26 approved2026-03-10Yes
SCA-124Cascade MutualCommercial HMO2026-02-23CM-77204Provider relationsConfirmedMissing directory dateResubmitted with date2026-03-20 approved2026-04-02Yes
SCA-127Summit AdvantageMedicare Advantage2026-03-09SA-40912K Iyer, network managerConfirmedApproved 2026-03-17 approved2026-03-30Yes
SCA-131Summit AdvantageMedicare Advantage2026-03-23SA-41203Network services queueConfirmedFile completeEscalatedNo response2026-04-13Pending

Two columns predict the timeline better than anything else on the sheet. A named reviewer closed SCA-127 in eight days and SCA-121 in ten. The unnamed queue took twenty-eight days to deny SCA-109 and has not answered SCA-131 at all. And SCA-124 lost three weeks to one missing field: the directory read date, which the adequacy log captures at intake precisely so the request does not go out without it. Four of six patients were seen by this practice, one was seen in network, and one is still waiting.

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What's in the pack

01

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.

02

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.

03

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.

04

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.

05

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.

06

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.

07

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.

08

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. 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. 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. 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. 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.

Sources

  1. eCFR42 CFR 422.116 — Network adequacy (opens in a new tab)
  2. eCFR42 CFR 438.206 — Availability of services (opens in a new tab)

Written by

Chandler Supple

Co-founder & CEO, River

Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.

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Reviewed by

Brian Joseff, Co-founder, River

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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.

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