How to Request a Network Exception

A network exception request is based on the insurance company having a gap in their services or providers. Therefore, you need to first determine if a gap exists.

Does a provider gap exist?

1. Contact your insurance company and request a list of providers for the service you are looking for. For example, therapists that specialize in anxiety after having a baby, or psychologists that conduct comprehensive neuropsychological assessments.
2. Call each provider to determine if they are a fit for your needs and be sure to take notes. It may be helpful to write out a list of questions to ask each person.

          Here are some questions to get you started:

1. 1. 1. Do you specialize in {diagnosis and/or symptoms}?
      2. Have you received specialized training for examining or treating {diagnosis and/or symptoms}?
      3. What percentage of your caseload includes working with {diagnosis and/or symptoms}?
      4. Where are you located?
      5. How soon can I get an appointment?

       You will also want to include any additional factors that you are considering. Perhaps you have multiple children and childcare creates specific day/time requirements for your treatment. Or you have ethnic or language requirements for your clinician. Sample additional questions may include:

1. 1. Do you offer evening appointments?
   2. Do you offer virtual sessions?
   3. What experience do you have working with Asian American clients?
   4. How do you approach psychological assessments with African American/Black clients?
   5. Do you offer services in Spanish? Is your paperwork available in Spanish?
   6. Do you have male clinicians?
   7. What percentage of your caseload includes working with children?

3. If you are successful in locating a provider, congratulations! Your network does not have a gap, you can schedule your appointment and receive treatment.

If there is a provider gap in your network…

Contact your insurance company to request a network exception. Remember that different insurance companies use different terms for this process. Examples include network exception, network deficiency, or single-case-agreement. Depending on your plan, they may want a referral from your primary care physician. When you call, have the following information ready (different plans want different information). If you have already selected your out-of-network provider, you may need to call them first if you are missing any of the following information.

1. 1. ICD-10 (International Classification of Diseases) or DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders) diagnosis code(s).
      • If you are seeking therapy, these are the diagnoses you have. If you are getting an assessment, this is tricky. They may want the code, but you are likely getting testing to see if there is a diagnosis. In this case, explain this to the customer service representative and give the code for the diagnosis(es) that your testing is considering.
   2. CPT (Current Procedural Terminology) codes. Think of these as “item numbers” for the services that you are receiving. For services at Learning Dynamics, you can look on the bottom of page two of our Insurance Coverage Guide for these codes.
   3. The out-of-network provider’s information. This includes their name, address, phone, fax, email, tax-ID and NPI number.
   4. Date range that you are hoping to receive the service. If granted, exceptions often have timelines, so you and your provider will want to pay attention.
   5. Your notes on why the providers in your network (if any) are not an option for you currently.

If your request is approved, congratulations! You can receive the care you need from an out-of-network provider at your in-network rate.

Important Reminders…

Of importance, you will want to request and receive your network exception before you receive services from an out-of-network provider. When you ask for the exception after you receive care, you may not be reimbursed. If you have read our previous blog about using insurance for mental health services, you will see that we always strongly recommend verifying coverage before receiving any service.

If your request is denied, you have options:

1. You can pay for the service with the out-of-network provider directly. If your plan has out-of-network coverage, you may want to use our Insurance Coverage Guide to assist you in verifying what your coverage may be. If you do not have out-of-network coverage, you will be responsible for the full rate and likely not receive any reimbursement.
2. You can appeal the denial of your request.

What to Appeal the Decision?

            Review your denial letter and pay attention to exactly why your request was not granted. You will want to directly address this in your letter. For example, your request may have been denied because there was a clinician available in their network. However, you contacted all the people on the list they provided and they were not available to see you in a reasonable amount of time or did not return your calls. This information can be included in your appeal letter.