What is a Network Exception?

What is a Network Exception?

A Network Exception is a resource that can be used to receive services from an out-of-network provider, at the rate it would cost you if they were a provider in your network. In these case-by-case situations, the insurance company makes an “exception” and treats the service as though it is in their network, even though the service is being provided by an out-of-network provider. Depending on the insurance company they may use different terms for this same service. For example, single-case-agreement or network deficiency. 

Why Would My Insurance Grant This?

It is your insurance company’s responsibility to make sure that their members have access to a comprehensive network of care providers. When they are unable to do accomplish this, there are rules and resources in place to help their members.

If you need a service that is medically necessary and covered by your insurance plan, but they do not have providers available, they may grant you an exception. “Not available” can mean there is not a provider in your network that performs this service, one that has the experience or specialty you require, or your network does not have a provider located near you. Another very common reason for granting an exception is a long wait time for providers in your network. Beginning in 2024, specific times are given to define reasonable wait times.” For services at our agency (non-urgent specialty care), this may be 30 days.

What is the Benefit?

If you have an HMO and you seek services at an agency that is not in your network (for example, Learning Dynamics), then your insurance company will most likely not cover any of the cost without a network exception. If you have a PPO or POS plan, then you can speak with your insurance regarding your out-of-network coverage to see what amount they cover. However, depending on your PPO or POS plan coverage, you still may want to consider a network exception. Some plans have significantly higher deductibles, co-insurance, and/or co-pays for out-of-network providers. With a network exception, your insurance company covers the out-of-network provider as though they were an in-network provider, which can save you a lot of money.

If you are unsure about what your insurance covers for mental health services (e.g., testing, therapy), you may want to download our Insurance Coverage Guide. We put together information and a list of questions that you may find helpful.

Do you think a network exception could be helpful for you? Then you may want to read our post “How to Request a Network Exception.”

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