Guide

How to write a network gap exception letter

A gap exception letter is the formal request asking your health plan to cover an out-of-network provider at in-network rates, because its own network can't meet your need. Plans decide on the evidence in front of them. A letter that proves the gap tends to get approved; one that only asks usually doesn't.

If you're new to the idea itself, start with what a network gap exception is. This guide is about the request.

Who sends it

You can send it yourself as the member. Your provider can send it, and so can a representative you've authorized with your plan, which usually means signing the plan's appointment of representative form first. Whoever sends it, the letter of medical necessity always comes from the treating provider.

For a child, the parent or legal guardian makes the request on the child's behalf, and the letter should say so.

What the letter needs to say

Who you are and which plan. Member name, date of birth, member ID, group number and plan name, exactly as on the insurance card. A request that can't be matched to your file sits unread.
The provider. Name, credentials, license number and state, NPI and practice address. The provider must be licensed in the state where you are during sessions, which matters for telehealth across state lines.
The need, specifically. Not "I'd prefer this therapist", but what the network has to provide and can't: a specialty such as eating disorders or trauma, a language, an age group, continuity of treatment that's working, or care that can't wait.
Proof the network can't meet it. The in-network providers you contacted from the plan's own directory, when, and what happened: not taking new patients, a waitlist of months, doesn't treat your condition, no longer in the network. Plans weigh this more than anything else.
The clinical support. Point to the enclosed letter of medical necessity from your provider.
Exactly what you're asking for. In-network benefits for this provider, for a stated number of sessions or period, starting on a stated date, with a written decision.
The basis. Your plan's own exception or network adequacy terms, if its documents have them. For mental health care, federal parity law also applies: a plan can't make access to mental health care harder than access to medical care.

What to attach

Your provider's letter of medical necessity.
Your network search: each provider contacted, the date and the outcome.
The relevant pages of your plan documents, such as the Summary of Benefits and Coverage.
An appointment of representative and a HIPAA authorization, if someone other than you is sending it.
Any earlier denial, if this follows one.

A sample outline

Keep it to a page or two. Plans review these quickly, and a clear structure gets read.

[Date]

To: [Plan name], [the department that handles network exceptions or behavioral health authorizations], [fax number or address]

Re: Request for a network gap exception
Member: [name], date of birth [date], member ID [ID], group [number]
Provider: [name, credentials], NPI [number], licensed in [state]

1. The request. I am asking the plan to apply in-network benefits to treatment with [provider] for [number of sessions or period], beginning [date].

2. The need. [What care is needed and why it has to have these features: specialty, language, age group, continuity or urgency.]

3. The network search. [Each in-network provider contacted from the plan's directory, the date, and the result.]

4. Medical necessity. The enclosed letter from [provider] explains why this care is necessary and why delay or a change of provider would cause harm.

5. The basis. [The plan's exception or network adequacy terms; for mental health care, federal parity law.]

Closing. Please send a written decision to [address or email]. [Name, relationship to the member if not the member, phone.]

Enclosures: [letter of medical necessity, network search, plan document pages, authorizations]

Why gap exception requests get denied

No real network search. One or two calls, or none written down.
The need reads as a preference. Liking a therapist isn't a gap in the network; a specialty the network lacks is.
A licensing problem. The provider isn't licensed where the patient is during sessions, or holds a supervised license the plan won't name on a request.
A thin or generic letter of medical necessity.
It never reached the right desk. Sent to the wrong department, or missing the member ID, so it's never matched to the file.
No specific ask. A request without a number of sessions or a period is easy to deny.

A denial isn't the end. You can appeal, and the strongest appeals answer the plan's stated reason directly.

After you send it

Call the plan a few days later to confirm it arrived and get a reference number. If you haven't heard back within a couple of weeks, follow up. When it's approved, keep the authorization number and its end date: claims filed before the authorization is on file can be paid out of network by mistake, and care after the end date needs a renewal.

Or have Inclara write and file it

This is exactly what Inclara does. We search your plan's network and document it, coordinate your provider's letter of medical necessity, write and submit the request, follow up until the plan decides, and appeal if it says no. There's nothing to pay upfront, and no fee unless your coverage is approved.

Frequently asked questions

Can I write a gap exception letter myself?

Yes. Any member can ask their plan for a network gap exception. What decides it is the evidence behind the request, especially a documented search of the plan's own network, and a letter of medical necessity from your provider.

Does my therapist have to write it?

Your therapist writes the letter of medical necessity, which goes with the request. The request itself can come from you, from your therapist, or from a representative you've authorized with your plan.

How long does the plan take to decide?

It varies by plan, and a few weeks is common. If waiting would put your health at risk, say so in the letter and ask for an expedited review. Always call to confirm the request was received and note the reference number.

What if the plan denies it?

You can appeal. Read the denial for the stated reason and answer that reason directly, usually with a fuller network search or a stronger letter of medical necessity. A first denial is often about missing evidence rather than the merits.

Rather not write it yourself? See whether your situation supports a gap exception, and we'll handle the letter.

No fee unless your coverage is approved. We'll follow up to ask what we need, or answer a few more questions now.