What 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.
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.