For healthcare providers in competitive states like California, getting credentialed with commercial insurance plans isn’t always straightforward. One of the most common barriers we encounter is market closures, where payers stop accepting new providers into their network due to oversaturation in a specialty or region.

When this happens, providers often feel stuck. Applications are denied, appeals may not be successful, and timelines for reapplication are unclear. At TriumpHealth, we help providers understand their options — including a lesser-known but highly effective tool: the Single Case Agreement (SCA).

What Are Market Closures in Provider Credentialing?

A market closure occurs when an insurance payer declares that its network is “full” for a certain specialty or location. This means they will not credential new providers, even if you meet all licensure and compliance requirements.

Market closures are especially common in:

• Behavioral health credentialing (LPCs, LMFTs, LCSWs)
• Primary care and pediatrics in high-density areas
• Specialties like OB/GYN, dermatology, and internal medicine in large metro counties

For providers, this can mean:

• Application denials even before review.
• Appeals with limited success.
• Months or years of waiting for an opportunity to reapply.

What is a Single Case Agreement (SCA)?

A Single Case Agreement is a one-time contract between a provider and an insurance company for a specific patient. If a patient needs care that cannot be reasonably provided by an in-network provider, the payer may allow an SCA to cover that patient’s treatment at in-network rates.

Key elements of SCAs:

• Patient-specific: Only applies to the named patient; does not make the provider fully in-network.
• Negotiated rates: Providers are often reimbursed at higher-than-network rates, which is why payers may resist.
• Medical necessity required: The payer usually requests documentation proving that in-network providers are unavailable or that continuity of care is required.

How SCAs Help in Market Closure Situations

Although SCAs are temporary, they can be a strategic tool for providers navigating credentialing challenges:

• Access to patients: Patients can still receive care from their chosen provider without excessive out-of-network costs.
• Claims history: By processing claims under an SCA, providers demonstrate demand for their services to the payer.
• Support for future credentialing: When reapplying, providers can use this history to strengthen their case for why they should be added to the network.
• Bridge to full contracts: While SCAs don’t replace payer contracts, they can fill the gap until the network reopens.

Leveraging HPSA Designations in Appeals

In addition to SCAs, providers located in Health Professional Shortage Areas (HPSAs) have another advantage. When appealing a denial due to market closure, TriumpHealth often highlights the provider’s HPSA status to demonstrate:

• Community need: Patients in HPSAs already face reduced access to care. Denying new providers only worsens shortages.
• Regulatory alignment: Both state and federal programs encourage insurers to support providers in underserved areas.
• Payer accountability: Emphasizing HPSA designation can strengthen the case that contracting with the provider is in the best interest of members.

While it doesn’t guarantee approval, HPSA designation is a powerful tool in payer appeals and when combined with SCAs, it creates a stronger argument for why the provider should be added in-network.

How TriumpHealth Supports Providers

At TriumpHealth, we help providers navigate credentialing challenges from start to finish. When market closures occur, we don’t stop at simply reapplying, we also:

• Guide providers through the SCA process, including documentation and payer submissions.
• Ensure CAQH, NPPES, and payer applications are accurate and ready for re-enrollment opportunities.
• Assist in drafting appeals and reapplications, leveraging factors like HPSA status to strengthen the case.
• Provide compliance-driven support to reduce delays and denials.

Conclusion

Market closures are frustrating, but they don’t have to end your credentialing journey. With the right approach including persistent appeals, HPSA-based arguments, and Single Case Agreements, providers can continue serving patients and build a stronger case for future payer contracts.

At TriumpHealth, our credentialing specialists work with providers nationwide to overcome these barriers, manage payer applications, and secure network contracts. To learn how we can help your organization achieve efficiency and compliance with our provider credentialing and CAQH maintenance services. Schedule a consultation today or contact us at [email protected] or (888) 747-3836 x0.