How to Get an Out-of-Network Exception (Gap Exception) for Health Insurance

Cut back on insurance costs with a network gap exception

So you have to go out-of-network for specialized healthcare? You are probably dreading paying more than usual for necessary care. But breathe easy: there may still be another option. Have you tried applying for an out-of-network (gap) exception from your insurer?

A gap exception, also called an out-of-network exception or a network exception, will lower your costs for specialized medical services. Anyone seeking out-of-network care can apply for a gap exception, meaning it probably won’t hurt to try. Applying can be a bit tedious, but with this step-by-step to insurance gap exceptions, the process should not take you too long. 

What is a gap exception for health insurance?

A gap exception is when an insurance payor covers an out-of-network provider at an in-network rate. Network gap exceptions happen when there is a gap in coverage (aka a network deficiency). It is usually recommended to request a gap exception before you start seeing your out-of-network provider, but the request can be made at any time.

For example, suppose you need to see a therapist for an eating disorder diagnosis, but there aren’t any eating disorder specialists who are both in your area and in-network with your insurance payor. You could be eligible for a gap exception.

If the gap exception is granted, you will pay your insurance plan’s in-network rate for your healthcare. Your in-network rate may be considerably cheaper than your out-of-network rate, and in-network care almost certainly has a lower deductible. Check out another one of our guides for more on the difference between in-network vs. out-of-network in health insurance. 

Why a Gap Exception Might Be Right for You

If you need to see a specific type of specialist and your health insurance plan does not have one in your network, is it fair for you to have to pay for your insurer’s lack of coverage? No. It is your insurance payor’s responsibility to provide you with a comprehensive network of care. When they fail to do that, the gap is their fault, not yours. And there are rules in place, like gap exceptions, to help protect you. 

That being said, no insurer particularly wants to give you a gap exception. Insurance payors have to do more work and spend more money to process a gap exception. Meaning they may try to deter you from applying if you ask them their opinion over the phone. Our opinion is that whenever you think you might be eligible, it is worth trying.  

If you think your insurance payor is breaking the rules by refusing to grant you a gap exception, you are not out of options. You can appeal to your state’s insurance department for help. They are in charge of regulating the sale of and compliance with all health plans in their state. (So they enforce the rules…)

Exceptions and Insurance Plan Types

There are a few different types of insurance plans, and some have a higher chance of approving a gap exception. If you want to see a more detailed breakdown of the various plan types, we also have a post on how to choose a health insurance plan. 

• Preferred Provider Organization (PPO) plans are the most likely to approve a gap exception. This is because they have preferred providers, but not an exclusive list of providers.
• Exclusive Provider Organization (EPO) plans are the least likely to approve a gap exception. This is because there is a set list of local health providers to choose from.
• Health Management Organization (HMO) plans may be eligible for a gap exception. But, you’ll likely need a referral from your primary care provider.

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Instructions

There are a few steps to take to apply (and receive!) a gap exception. It can be a time-consuming process, but it can also be a beneficial one. Although there are no guarantees when it comes to gap exceptions, follow these steps carefully and you will maximize your chances of receiving one.

1. Determine if there is a network deficiency.

Call your insurance company and ask them for a specific kind of specialist. For example, you could say I need a list of therapists that specialize in Obsessive Compulsive Disorder. They will then provide you with a list of specialists.

2. Contact your insurance’s list of providers.

You will need to contact all of these providers and ask them a few questions to gauge their ability to treat you.

Hi *insert provider name*. I have *insert diagnosis here* and my insurance gave me your name as a specialist to see. I have a few questions to make sure you’re able to support me and my needs. 

1. Do you specialize in *insert diagnosis here*?

2. What percentage of your caseload has *insert diagnosis here*?

3. Have you received any specialized training for *insert diagnosis here*?

If there are providers who do specialize in your needs, then getting a network gap exception may be more difficult. However if you have determined there is a network deficiency, then continue to step three.

3. If you've determined that there is a network deficiency…

The next step is to call your insurance company and request a gap exception. Tell them there aren't any providers in-network that meet your specialized care needs. In order for them to process the gap exception, you will need the CPT code, diagnosis code, and likely your provider's NPI number and Tax ID number. This information can be found on a superbill, or you may need to contact your provider’s office.

If you are approved for a network gap exception, congrats! We are so excited that you are able to access the care you need at an in-network rate.

If you are NOT approved for a network gap exception, you have other options:

1. Pay for your specialist provider out of pocket and accept that you must pay an out-of-network rate.
2. See your specialist provider and submit a superbill to your insurance payor for reimbursement.

Want to know more about #2? In a nutshell, here’s how it works: Once you’ve hit your out-of-network deductible, your insurance payor will likely reimburse a percentage of your payments. You will need a complete superbill to send a claim into your insurance payor, and follow their claims process. (Tip: Check our Medical Claims Forms Database for links to many insurers’ claim forms!) Or, skip all this hassle with SuperBill!

Communication is Key

Above all, maintaining a calm and professional tone in your communications is essential when dealing with insurance companies. Just like in a letter of appeal for insurance claim denial, taking your frustration out on your insurance payor will only hurt your case’s chances. Often, a thorough, well-written explanation of your circumstances can be the difference between acceptance and rejection. 

Consider how large of a gray area you have in certain situations. For instance, suppose you are seeking a very specific type of therapeutic care, EMDR therapy, because you have tried several other therapeutic methods without success. If your insurance network does not have anyone in your area who specializes in EMDR, your insurer may try to send you to a different kind of therapist. 

But this is because your insurer does not have insight into your particular medical history. If you explain the situation clearly and you include a referral from the therapist who wants you to try EMDR, your insurer should grant you a gap exception.

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