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What is a gap exception and how to get one

Defintion of a gap exception and how to obtain one for your patient

A gap exception (also referred to as a network deficiency, gap waiver, in-for-out, etc) is a request to honor a patient's in-network benefits, even though they are seeing an out-of-network provider.

This can be advantageous for the patient depending on their policy benefits. A gap exception allows the patient to utilize their in-network benefits, which usually have a lower deductible and higher coverage percentage. This can also be key in obtaining any coverage at all if the patient has a policy that only offers in-network coverage and the provider they are seeing is out-of-network, for example, many HMO policies only offer in-network coverage.

Keep in mind, a benefit verification should be performed before making the decision to request a gap exception, as this will reveal what the best next step is. In most cases, a patient's in-network benefits will yield less out of pocket expense for the patient, so a gap exception would be advantageous. However, there are exceptions to this! For example, a patient may have seen many out-of-network providers that year and already met their out-of-network deductible, however not met any of their in-network deductible yet. This is why the benefit verification is key.

If the provider is out-of-network, and the policy only offers in-network coverage, a gap exception will be necessary to obtain any coverage.

Why would an insurer allow in-network coverage to an out-of-network provider?

In short, an insurers allow gap exceptions because they do not have an in-network provider for the patient to go to, so it is considered a "network deficiency".

Many insurers will allow a gap exception if there is not an already a provider contracted in their network rendering the same services within a reasonable distance to the patient. The insurance company determines what the reasonable distance is, which generally lies between 30-50 miles.

How to obtain a GAP Exception for your patient:

Some insurers will accept a written & mailed or faxed request from the provider, while some insurers will require the patient call to make the request. Below is an example of language for a gap exception request:

"There are no in-network providers within a reasonable distance to this patient who can provide this treatment/service/equipment.

Please honor the patient’s in-network benefits to this out of network provider on a one time basis as a courtesy to your beneficiary to receive the medically necessary treatment they have been prescribed by their physician"

The Golden Rule for gap exceptions:

Don't give up so easily!

If your gap exception request is denied, make sure to find out why. We have seen, many times, insurers deny gap Exception requests on the basis they that there are in-network providers for the patient to go to, only to find out upon further investigation that the in-network providers that the insurer provided do not provide the service needed!

For example, an insurer may mistakenly identify DME and/or orthotics suppliers that supply equipment such as CPAP machine, wheelchairs, etc, instead of a DDS/DMD for oral appliances for obstructive sleep apnea.

If you find an error, ensure to appeal the decision and it will likely be overturned.

Below is an example of an approval from an insurer for a GAP exception request from a dentist for an oral appliance for obstructive sleep apnea: