Healthcare SCA Agreement

HEALTHCARE SINGLE CASE AGREEMENT (SCA)

Parties

This Single Case Agreement (SCA) is entered into by and between:

Patient and Coverage Information

Date of Birth:    Gender: Male   Female   Other

Clinical and Service Request

Proposed Start Date:    Proposed End Date:

Medical History (Relevant)

Financial Terms and Payment

Agreed Payment Arrangement: Provider will accept as full payment for the services described above the amount or methodology identified below as accepted by Payer for this single case.

Patient financial responsibility (copayments, deductibles, coinsurance) shall be:

Authorization Number Issued by Payer:    Authorization Expiration Date:

Administrative and Operational Provisions

Prior Authorization and Documentation: Provider shall submit clinical documentation and records reasonably requested by Payer to support the medical necessity of services. Payer will review submitted documentation in good faith and provide a determination in accordance with the terms of this SCA.

Claims Audit and Reconciliation: Payer reserves the right to audit claims and documentation to confirm compliance with the terms of this SCA. Any required repayment or adjustment shall be limited to substantiated overpayments and follow standard reconciliation procedures mutually agreed upon.

Term and Termination: This SCA is effective for the single case defined by the patient and authorization number and terminates upon completion of services and final payment, or upon the Authorization Expiration Date above, unless earlier terminated by mutual written agreement or material breach with a fifteen (15) day cure period.

Legal Provisions

Compliance with Law and HIPAA: Each party shall comply with all applicable federal and state laws and regulations, including but not limited to statutes governing privacy and security of protected health information. Each party shall implement and maintain administrative, physical, and technical safeguards to reasonably protect PHI in its possession.

Confidentiality: Except as required by law or expressly permitted by this SCA, the parties shall treat as confidential all non-public business and clinical information exchanged in connection with this SCA.

Indemnification: Provider agrees to indemnify and hold harmless Payer from claims arising from Provider's negligent acts, omissions, or willful misconduct in the provision of services under this SCA. Payer agrees to indemnify and hold harmless Provider from claims arising from Payer's negligence in payment or administration of this SCA.

Limitation of Liability: Except for liability arising from willful misconduct or gross negligence, neither party shall be liable for incidental, special, punitive, or consequential damages.

Dispute Resolution: The parties shall attempt in good faith to resolve any dispute arising out of this SCA. If unresolved, disputes shall be referred to binding arbitration in the jurisdiction specified below.

Governing Law: This SCA shall be governed by and construed in accordance with the laws of the state of , without regard to choice of law principles.

Acknowledgments and Signatures

By signing below, each party certifies that it has authority to enter into this Single Case Agreement and that the terms set forth herein accurately reflect the agreed arrangement for services, payment, and administrative responsibilities specific to this case. Each party further certifies that all information provided in this SCA is true and correct to the best of its knowledge.

Patient / Member Acknowledgment: The patient or authorized representative affirms that they request the services described above, understand any patient financial responsibility, and consent to the release of medical information as needed for this authorization and claims processing.

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