It’s all too common that your insurance provider will approve a medically necessary service or piece of equipment, but you then find yourself in a challenging predicament where said service or equipment is provided by an out-of-network supplier. You will end up paying more than you would have paid if you use an in-network provider because out-of-network rates are often skyhigh, and most individuals do not have the financial ability to pay the out-of-network deductible.

If you find yourself in a situation – don’t panic just yet. There’s quite a clever way to work around this issue, but be aware that your health insurer is not going to be keen to offer this piece of information upfront since it will benefit you, and not them.

Network Gap Exception

A network gap exception, also known as a clinical gap exception, is a tool health insurance companies use to compensate for gaps in their network of contracted healthcare providers. 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 insurance grants the network gap exception, you’ll pay a lower in-network deductible, co-pay, or coinsurance for that particular out-of-network care.

Important to note that your health plan isn’t going to be eager to grant you a network gap exception because it’s more work for them, but if your health plan doesn’t have an in-network provider that’s in your area, usually within 50 to 100 miles, or if the provider is incapable of providing health care service 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.

For more detailed information on Network Gap Exceptions – Click Here

What You’ll Need for Your Exception Request

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

• The CPT or HCPCS code describing the healthcare service or procedure you need.
• The ICD-10 code describing your diagnoses.
• The out-of-network providers contact information.
• A date range during which you expect to receive the requested service.
• The names of any in-network providers of the same specialty within your geographic range area along with an explanation as to why that particular in-network provider is incapable of performing the service.

How Does It Work?

If your healthcare provider grants you approval for prior authorization of a particular service, but said services are out-of-network then you can request a network gap exception. This will require you filling out a form to send back to your insurance company.

It’s really important to note that you’re only likely to be granted a network gap exception if you meet the following criteria:

1. The care you’re requesting is a covered benefit and is medically necessary
2. There are no in-network providers capable of providing the service you need within a reasonable distance.

This is a really great resource because when you are an individual purchasing your own private health insurance plan through the marketplace, for example, you are oftentimes very limited with the healthcare providers you can see within a limited geographical range.

Important Note:

If your healthcare provider approves a network gap exception and the provider of the service you are requesting agrees to in-network rates from your health insurance company then you are good to go – meaning you don’t have to outlay any financial costs to get said service.

However, it’s all too common that many out-of-network suppliers of a particular service will not work with your insurance provider at in-network rates because they end up losing money.

If this happens you can request that your healthcare provider write you a check for the entire billable amount. What this means is that you will have to pay for the said service or equipment upfront, but then can submit a claim to be reimbursed for 100% of the billable amount.

This is great in that you do not technically have to pay for a particular service or piece of equipment, but you do have to pay out-of-pocket until you get reimbursed, which usually takes between 30 to 60 days.

REMEMBER: If an out-of-network provider will not work with you and you have to pay upfront, PLEASE make sure you get in writing from your health provider that they will pay 100% of the billable amount for your records.

TIP:

Before submitting for Prior-Authorization it is very easy to call the provider selling said service or equipment you are requesting to find out if they are in-network or out-of-network. If they are out-of-network you can avoid many steps and, most importantly, time by following these steps:

• Whether you, the patient, or durable medical supplier is submitting for prior authorization and know that the requested service or equipment is provided by an out-of-network supplier can fill out an extra form called: “In-Network Benefit Review Form”
• The purpose of this form is similar to the network gap exception, but you are just filling out the paperwork prior to being approved from your insurance company. So, when your insurance company is reviewing your prior authorization form they can simultaneously review the in-network benefit review form to ensure if what you are requesting is not only medically necessary, but if they cannot find an in-network provider for said service or equipment in your area they can automatically grant you in-network benefits with your out-of-network provider.