Patient Script for Requesting a GAP Exception

Some insurance companies, such as Aetna, only allow the patient or an in-network provider initiate a gap exception (also known as a network waiver.) This is a script that you can give to your patients:

📞 Patient Script: Requesting a GAP Exception / Single Case Agreement

Before You Call:
Make sure you have the following ready:

• CPT Code(s) (provided by the provider’s office)

• Diagnosis codes and descriptions (provided by the provider’s office)

• Provider Name, Address, Tax ID, and NPI (also provided by the office)

• Pen and paper (to write down case numbers and reference numbers)

Step-by-Step Script:

Call Member Services (the number is on the back of your insurance card).

When a representative answers, say:

1. Start the Request:

“Hi, my name is [Your Name], and I am a member of your plan.
I’m calling to request a GAP exception, network exception/waiver, or single case agreement for medical services I need.”

2. Provide CPT Code(s):

“The procedure code(s) are: [Read codes provided by the office]. I’m asking that these be covered at the in-network benefit level.”

3. Provide the Diagnosis:

“The diagnosis codes are: [Read diagnosis provided by the provider’s office].”

4. Explain the Reason for Request:

“I’m requesting this exception because there are no in-network providers within a 50-mile radius of my location who can perform these services.”

5. Provide the Out-of-Network Provider’s Information:

“The provider I would like to see is:
• Provider Name: [Insert]
• Address: [Insert]
• Tax ID Number: [Insert]
• NPI Number: [Insert]”

6. Ask for Authorization and Instructions:

“Can you please provide me with:

• A case number

• A reference number for this call

• And the fax number where we should send the medical records?”

✅ After the Call:

Make sure to write down:

• Case Number

• Reference Number

• Representative’s Name

• Date and Time of Call