What is a gap exception and how to get one

definition of a gap exception and how to get one for your patient

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

Please note that a benefit verification should be completed prior to making the decision to request a gap exception, as this will reveal the best next step. In most cases, a patient’s in-network benefits will result in lower out-of-pocket costs 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 has already met their out-of-network deductible, but has not yet met any of their in-network deductibles. That’s why verification of benefits is key.

Reading: What is a gap exception for health insurance

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

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

In short, an insurer allows gap exceptions because they don’t have an in-network provider for the patient to go to, which is considered a “network gap.”

Many insurers will allow a gap exception if there is no contracted provider in their network that provides the same services within a reasonable distance of the patient. the insurance company determines what is a reasonable distance, which is generally between 30 and 50 miles.

how to get a gap exception for your patient:

some insurers will accept a & application mailed or faxed from the provider, while some insurers will require the patient to call in to apply. Here is an example language for a gap exception request:

“there are no network providers within a reasonable distance of this patient who can provide this treatment/service/equipment.”

honor the patient’s in-network benefits to this one-time out-of-network provider as a courtesy for your beneficiary to receive medically necessary treatment prescribed by their physician”

the golden rule for space exceptions:

Don’t give up so easily!

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

for example, an insurer may misidentify dme and/or orthotics providers supplying equipment such as cpap machines, wheelchairs, etc., rather than a dds/dmd for oral obstructive sleep apnea appliances .

if you find an error, be sure to appeal the decision and it will probably be overturned.

The following is an example of an insurer approval for a dentist’s gap exception request for an obstructive sleep apnea oral appliance: