Keep the clients who are struggling with the out-of-network cost

Many of your clients pay your full fee and get little or nothing back. Their out-of-network benefits sit behind a separate deductible, usually far higher than the in-network one, and most never meet it. A network gap exception moves them onto their in-network benefits. Nothing changes about how you practice.

What changes for you: nothing about your fee

• Your fee stays the same. Your client keeps paying you directly, as they do now.
• No contract, no credentialing, no billing. A gap exception is a decision about your client's benefits. It doesn't make you in-network or set your rate.
• Free for you. Your client pays Inclara only if their plan approves.

The one thing we ask is a letter of medical necessity, done on a short form: diagnosis, current presentation, the treatment you provide, and why this client needs you in particular. You sign on the page, and the letter is generated for you. Your details are saved, so the next one takes less.

What changes for your client

Once the plan approves, your sessions are reimbursed at your client's in-network level: their in-network deductible and coinsurance, against the plan's allowed amount. For a client who was getting nothing back because they'd never reach the out-of-network deductible, that's the whole difference between affording weekly sessions and cutting back.

It works on plans with no out-of-network benefit too, where it creates coverage that wasn't there.

How it works

1. You mention us to a client. Hand them our one-page client handout (PDF, to print or email), or tell us about the situation and we'll send you a link to pass on. You don't share anything about them with us; they start on their own.
2. We build the case. We read their plan documents, search the plan's own network for someone who can meet the need, and document what we find.
3. We ask you for the letter. One email with a link to the form. We tell you which grounds the case rests on, so you know what to address.
4. We file, follow up and appeal. We submit the request, chase the plan until it decides, and appeal if it says no. Plans approve care in blocks of sessions, so we handle renewals too, and ask you for an updated letter with your last answers filled in.

Which clients are a good fit

• Adults on an employer health plan. We don't handle Medicare or Medicaid.
• A need the network can't meet: a language or culture, a specialty such as eating disorders, OCD, perinatal or trauma work, continuity of treatment that's working, or care that can't safely wait.
• You're fully licensed where the client is during sessions. For telehealth across state lines, that means a license or compact privilege in the client's state.

A client who simply prefers you, when the network has comparable clinicians available, is a weak case. We'd rather tell you that upfront than file it.

Already out of network?

If you've left insurance panels or never joined them, you're already an out-of-network provider: clients pay you and submit superbills for whatever their plan will reimburse out of network. A gap exception is the one route that improves their coverage without you joining a network or accepting a lower rate. For the mechanics, see what a network gap exception is and what the request needs to say.

Frequently asked questions