Network Gap Exception—What It Is & How It Works

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What a Network Gap Exception Is

A network gap exception is a tool health insurance companies use to compensate for gaps in their network of contracted health care providers. When your health insurer grants you a network gap exception, also known as a clinical gap exception, it’s allowing you to get health care from an out-of-network provider while paying the lower in-network cost-sharing fees.

Without a network gap exception, when you see an out-of-network provider, you’ll pay more than you would have paid if you had used an in-network provider.

If you have an HMO or an EPO, your health plan won’t pay one dime of the cost of your out-of-network care unless you get a network gap exception. If you have a PPO or POS plan, your health plan will help you pay for care you get out-of-network. However, your deductible, coinsurance and copayments will be significantly larger when you use an out-of-network provider than when you use an in-network provider.

Requesting a network gap exception from your health insurer is formally asking the insurer to cover care you get from an out-of-network provider at the in-network rate. If your insurer grants the network gap exception, you’ll pay the lower in-network deductible, copay, or coinsurance for that particular out-of-network care.

How a Network Gap Exception Works

First, be aware that your health plan isn’t going to be eager to grant a network gap exception. It’s extra work for them, and it might end up being expensive for them.

However, if the health plan doesn’t have an in-network provider capable of providing the health care service that you need, it’s not fair to make you pay higher cost-sharing just because the health plan doesn’t have a sufficiently robust provider network in your area. So, insurers can grant a network gap exception to allow you to get the care you need from an out-of-network provider without paying more than you should have to pay.

You’re unlikely to be granted a network gap exception unless the following are true

  1. The care you’re requesting is a covered benefit and is medically necessary.
  2. There is no in-network provider capable of providing the service you need within a reasonable distance. Each health plan defines for itself what a reasonable distance is. In some health plans, it might be 50 miles. In others, it could be a larger or smaller distance.

If your situation fits the above requirements and you’ve located an out-of-network provider that meets all of your needs, you may submit a request to your health insurance company for a network gap exception. In some cases, the out-of-network provider may be willing to do this for you; in other cases, you’ll have to do it yourself. You should ask for the network gap exception prior to getting the care. If you wait until after you’ve gotten the care, your health plan will process the claim as out-of-network and you’ll pay more.

The information you’ll need at hand when requesting a network gap exception includes

  • The CPT or HCPCS code describing the health care service or procedure you need.
  • The ICD-9 or ICD-10 code describing your diagnosis.
  • The out-of-network provider’s contact information.
  • A date range during which you expect to receive the requested service. For example, from February 1, 2016 to July 31, 2016.
  • The names of any in-network providers of the same specialty within your geographic area along with an explanation as to why that particular in-network provider isn’t capable of performing the service.

A network gap exception doesn’t give you carte blanche to see any out-of-network provider for whatever service you wish at any time you wish. Instead, when an insurer grants a network gap exception, the exception usually only covers one specific service provided by a particular out-of-network provider during a limited time frame.

To make sure the network gap exception includes the services you need, get the CPT codes, HCPCS codes, and ICD-10 codes from your out-of-network provider. If this is difficult because you haven’t actually had an appointment with that provider yet, the physician who referred you may be able to provide you with the needed medical codes.

Are there any in-network providers of the same specialty as the out-of-network provider you’re requesting a network gap exception for? If so, you need to explain to your health insurance company why you can’t use the in-network provider.

Here’s an example. Let’s say you need ear surgery and are requesting a network gap exception to cover an out-of-network otolaryngologist doing the surgery. However, there’s an in-network otolaryngologist within your geographic area. The in-network otolaryngologist is elderly, has a hand tremor, and thus no longer performs surgery. If you’re not proactive in explaining to your health plan why the in-network otolaryngologist can’t provide the service you need, your request is likely to be denied.

Lastly, if your request is denied, don’t give up. Call your health insurance company to find out why, exactly the request was denied. Sometimes, it’s denied for a simple reasons like the insurer was unable to contact the out-of-network provider’s office, the insurer thinks there are in-network providers capable of providing the same service, or the insurer doesn’t have your correct address and thus thinks you live closer to  in-network providers than you do. All of these mistakes can be cleared up. Once you understand why the request was denied, you can either appeal that decision or submit a brand new request which includes additional information to bolster your request.

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