Your deadline
At least 180 days from RECEIPT to appeal. A gap-exception request is often faster than an appeal and can be made while the clock runs.
This is not everyone’s clock. Medicaid or CHIP, Medicare, TRICARE, VA health care and a church or government employer plan run on different rules. Do not assume the number above is yours.
Work out your own deadlineWhat to do
Get the plan's list of in-network surgeons for the specific procedure
Ask in writing for in-network providers who perform your named procedure, not for a specialty directory.
Call every name on the list and write down what happens
Date, time, who you spoke to, and the outcome: not taking new patients, does not perform this procedure, wait beyond a clinically reasonable time, or not actually in network. This log is your evidence.
Request the gap exception in writing
State the procedure, the surgeon you need, that no in-network provider can perform it, and attach the log. Ask explicitly for in-network cost sharing.
Ask for the decision in writing before anything is scheduled
A verbal yes is not a benefit determination and will not survive a billing dispute.
Confirm what the approval actually covers
A gap exception sets your cost sharing. It is not the same as an agreement about what the plan pays the surgeon — that is a single case agreement, and you may need both.
If it is denied, appeal on network adequacy
A network that cannot deliver a covered benefit is a network adequacy problem, and in state-regulated plans the insurance department cares about that.
What kind of network you have decides how hard this is
This is not the same question as which plan type you have, and it is worth separating them. Your PLAN TYPE — self-funded, fully insured, marketplace, Medicaid, Medicare — decides which law governs your appeal, your deadline, and who enforces it. Your NETWORK TYPE decides whether going out of network is expensive or simply not covered. The first sets your rights; the second sets your argument.
PPO: there is an out-of-network benefit. You can generally see the surgeon and pay more, and the gap exception is an argument about PRICE — cover this at the in-network rate because the network could not deliver it. Losing still leaves you a route, at a cost.
EPO and HMO: there is usually no out-of-network benefit at all, except in an emergency. So a gap exception is not about price, it is about whether the surgery is covered by any route. That makes network adequacy the whole case rather than a discount argument, and it is the reason an EPO denial for a procedure no in-network surgeon performs is worth appealing hard rather than paying around.
HMO and POS additionally require a referral from your primary care doctor for specialist care. A denial that turns on a missing referral is a PROCEDURAL denial, not a clinical one, and it is often fixable by getting the referral and resubmitting rather than by arguing medical necessity. Read the stated reason carefully before you answer the wrong question.
Your plan documents name the network type on the first page, and your insurance card usually prints it. If you cannot tell, ask in writing whether your plan has any out-of-network benefit for the procedure you need, and keep the answer.
Two arguments, and each one stands on its own
A gap exception request has two independent legs, and it is worth making both because a plan can defeat one without touching the other. The first is that no in-network provider is AVAILABLE to you in a medically reasonable time. The second is that no in-network provider offers an EQUIVALENT service, which is a different claim and turns on capability rather than on scheduling.
Plans usually answer the first and ignore the second, or answer the second with a sentence asserting that in-network providers have the same skills. If your plan document does not contain a same-skills standard, ask where that standard came from — a plan applying a test that is not in its own document is a separate problem worth naming.
What 'available' means in practice, and the four ways it fails
Available is a practical question, not a directory question. A name on a list is not availability, and there are four distinct ways a listed provider turns out not to be available. Log which one applies to each name, because they are different arguments.
- The wait is too long. A provider whose first consultation is years out is not available for care you need this year. Record the wait with the name of the person who told you and the date.
- There is a prerequisite you cannot meet in time. Some surgeons require a course of preparation finished before they will schedule. If that adds a year, they are not available for a date months from now.
- They perform a different procedure or technique. This is the one people miss: providers are listed against broad procedure codes, and two techniques billed under the same code are not the same operation. Ask specifically whether they perform the technique your authorisation names.
- They do not do it at all. Directories are wrong more often than plans admit. Call, confirm, and record the answer.
Why the call log is the whole case
The plan's position is that its network is adequate. Your position is that you called every surgeon on their list and none of them could do the procedure. Whoever has the more specific record wins that argument, and only one side is keeping one. Write it down while you are on the phone.
Common questions
- What is the difference between a gap exception and a single case agreement?
- A gap exception sets what you pay. A single case agreement sets what the plan pays the out-of-network surgeon. Getting one without the other is where people end up owing money they did not expect.
- What counts as no in-network provider?
- Nobody who performs the procedure, nobody taking new patients, or nobody available within a clinically reasonable time or distance. All three are network-adequacy arguments.
Where to go next
Sources for the legal points on this page
- The ACA appeal framework: internal appeal, then binding external review
Federal — non-grandfathered group health plans and issuers · effective in force
29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
Also on this page, without a citation yet
- How PPO, EPO, HMO and POS plans typically differ on out-of-network benefits and referrals. That is a description of how these plan designs usually work, not a legal rule, and your own plan document governs. Some EPOs do carry a limited out-of-network benefit and some PPOs require referrals for particular services. Read your Evidence of Coverage or Summary Plan Description rather than relying on the label.
- That state insurance departments enforce network-adequacy standards, and what those standards require. Network adequacy is state law and it varies: some states set time-and-distance or wait-time standards by specialty, others do not, and a self-funded employer plan is generally outside a state department's authority regardless. This page describes the shape of the argument rather than a rule we verified for your state. Ask your insurance department what standard applies and whether it regulates your plan.
- That any particular plan calls this a gap exception. The same request goes by network exception, network deficiency, network gap, out-of-network authorization and authorized services, and a plan may not recognize the phrase this page uses. Ask for the process by description rather than by name.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.